Insight and mood disorder. Dr. Daniel Mograbi

Transcription

1 Insight and mood disorder Dr. Daniel Mograbi

2 Definition of insight Aubrey Lewis (1934) A correct attitude to a morbid change in oneself In psychiatry, the term most commonly used is loss of insight In neurology, often lack of awareness is referred to as anosognosia Psychological perspectives privilege the term denial There are different objects of insight (Markova, 2001) Mechanisms involved may be different in each condition

3 A case of reduced insight?

4 Clinical implications - Treatment compliance (e.g. Patel and Prince, 2001) - Patient safety (e.g. Starkstein et al., 2007) - Caregiver burden (e.g. Seltzer et al., 1997)

5 Insight and mood Insight (of a condition, symptoms or cognitive deficits) shows a consistent relationship with mood state More preserved insight is associated with lower mood state Evidence for this association is present across clinical conditions E.g. AD (Clare et al., 2011), TBI (Fleming et al., 1998), psychosis (Saaedi et al., 2006) Mania in AD associated with reduced insight (Migliorelli et al., 1995)

6 Insight and mood However, this association is not found in all studies Construct being measured In dementia, association found with dysthymic mood (Harwood et al., 2000), but not with major depression (Lopez et al. 1994) Cooke et al. (2007) Insight in psychosis correlated with self-esteem but not depressive symptoms Sampling Exclusion of patients with co-morbid psychiatric conditions Sample size association usually seen in large studies (e.g. Aalten et al. 2005) Setting Clinical settings contributing to biases; association with depression seen in the only community-based study about awareness in dementia (Mograbi et al., 2012; n=897)

7 The direction of causality Insight causing depressed mood (reactive depression) Intuitive account; clinical anecdotes supporting this notion (e.g. reaction to diagnosis disclosure or neuropsychological assessment) This perspective is often linked to a psychological account of unawareness (denial), suggesting a protective role for loss of insight

8 The direction of causality (cont.) Depressed mood leading to insight Negative bias affecting reporting of problems Plenty of evidence for biases in cognition caused by depression (e.g. facial processing) A prediction here is that this would be global, instead of specific to a modality (Bertrand et al., submitted) Depressive realism Loss of positive biases (e.g. overconfidence bias, optimism bias)

9 Insight into bipolar disorder Bipolar disorder as a natural experiment on the relationship between mood and insight Da Silva et al. (2014) 65 patients with bipolar disorder, who were assessed in at least 2 different mood states (euthymia, depression, mania; withinsubjects design) Appraisal of mood with a visual analogue scale covering 16 pairs of traits

10 Insight into bipolar disorder No significant differences between mania and euthymia in self appraisal of mood state for any of the 16 traits Significant differences between depression and euthymia or mania

11 Insight into bipolar disorder Da Silva et al. (2015a) 48 bipolar disorder patients evaluated at 4 different mood states (euthymia, depression, mania, mixed state) Insight was evaluated with a composite score calculated with item 11 of the Young Mania Rating Scale and item 17 of the Hamilton Depression Scale Lower insight in mania and mixed-state in relation to euthymia and depression Regression models suggested that YMRS score was an important predictor for loss of insight

12 Insight into bipolar disorder Factor analysis of the Insight Scale for Affective Disorders in a sample of 95 BD patients (Da Silva et al. 2015b) 4 factors covering different aspects of insight into bipolar disorder Replicates findings in other conditions, such as dementia, showing the heterogeneity of insight (Dourado et al., 2014)

13 Implicit reactivity Patients react negatively to clinical assessments and make symbolic references to impairments despite having little insight about their performance (Weinstein & Kahn, 1955; Prigatano & Weinstein, 1996) Misoplegia in anosognosia for hemiplegia (Pearce, 2007) Qualitative work suggesting emotional reactions of unaware neurological patients when talking about disability (Turnbull et al., 2002)

14 Emotional reactivity and insight Experimental studies Emotional stroop in people with dementia (Martyr et al., 2011) Patients and caregivers showed a similar interference effect when colour-naming dementia-related words forgetful, memory vs. formality, fiction In the patient group, this effect was not correlated with insight of condition, which suggests implicit processing of information Similar findings have been observed with hemiplegic patients (Nardone et al., 2007; Fotopoulou et al., 2010, Cocchini et al., 2010)

15 Implicit reactivity in AD Mograbi et al. (2012) The study investigated emotional reactivity in response to failure in cognitive tasks Programmed computer tasks based on success-failure manipulation Performance in the tasks was controlled, but this was not informed to participants Tested in a group of 23 AD patients (mild to moderate severity) and 21 controls

16 Experimental design 2 experiments: one with reaction time tasks and another with memory tasks Initial trials captured the individual performance threshold of participants, and depending on the experimental condition, trials were either above or below the participants threshold In each experiment, there was a task with 90% success trials and another with 90% failure trials

17 Experimental design Background measures Eg: Cognitive level (ACE-R) Mood (AES, Cornell) Anosognosia (AQ-D) Memory (CERAD word list) Self-report of emotion before and after each task Filming of facial expressions (FACS) Awareness of performance (% Estimation % Actual performance)

18 Results Experiment 1 Reaction time tasks Impaired awareness of performance in the AD group, but emotional reactivity comparable to controls. Emotional reactivity not correlated with awareness of performance.

19 Results Experiment 2 Memory tasks Similar pattern of impaired awareness of performance but normal emotional reactivity, with no correlation between these variables.

20 Video example Results

21 Implicit reactivity In summary, patients with AD react to the experience of failure, despite not having fully preserved awareness This reactivity is not correlated with awareness of performance 2 potential explanations: Memory (mnemonic anosognosia) Integration of information (primary anosognosia)

22 Cognitive Awareness Model Agnew & Morris (1998), Morris & Hannesdottir (2004), Morris & Mograbi (2013)

23 Insight and apathy In the context of dementia, apathetic patients have less insight (Derousne et al., 1999, Spaletta et al., 2012, Starkstein et al., 1996, 2001, 2005) Anosodiaphoria? Apathy would interfere with error monitoring by depriving errors of their affective signature Apathy is characterized by loss of motivation and participation in goal directed activity, a context in which monitoring of errors becomes less relevant Brain networks associated with apathy have also been implicated in anosognosia (Ott et al., 1996) or error monitoring (Taylor et al., 2006)

24 Reactivity to errors and executive anosognosia The main function of the comparator mechanisms is to evaluate current performance, relaying information about errors If this mechanism is preserved, but there are other causes for unawareness, then there is the possibility of implicit reactivity Conversely, if there is an impairment caused by apathy, there is no evaluation of errors as such, and patients remain oblivious to their mistakes

25 Apathy and anosognosia Rosen et al. (2014) Comparison of patients with FTD, AD and controls in several metacognition measures Patients with FTD and AD were worse than controls in terms of metacognition, but only FTD (and not AD) patients were not able to benefit from explicit feedback Rosen et al. (personal communication) There is an association in patients with FTD between reduced emotional reactivity to errors (measured by facial expressions) and insight Video example

26 Modelling the influence of mood in insight Depression negative bias or depressive realism impacting evaluation of self-ability (self appraisals [MAS] or biased recall of personal information [PDB]) Apathy affective blunting hindering monitoring of performance (Mograbi & Morris, 2014)

27 Acknowledgements Participants and families Collaborators Robin Morris Richard Brown Andrew Brand Dan Stahl Megan Pritchard Howie Rosen Christian Salas Elie Cheniaux Rafael da Silva CAPES foundation Genichi and Kazu for the hospitality