Letters to the Editor
Insight, Knowledge, and Beliefs About Illness in First-Episode Psychosis
Dear Editor:
Psychoeducation about psychosis is a valuable therapeutic strategy in that it may improve understanding of the illness itself and potentially modify patients’ behaviours and attitudes (1). In our comprehensive Early Psychosis Program (EPP), we offer education about the illness in family intervention sessions and through case and psychiatric management with a specifically designed Psychosis Education Group (2). We describe here a study that explored the impact of providing education about psychosis to individuals experiencing a first episode of a psychotic illness. Of the 78 subjects, 57 were men and 21 were women (mean age 24.7 years). They had been attending EPP as outpatients for between 12 and 30 months and had either full or partial remission of positive symptoms. We designed a multiple-choice questionnaire (the Knowledge About Psychosis Questionnaire) based on existing knowledge questionnaires in the literature and on the material taught in our program (3). We used the Insight Scale (4) to obtain information on insight regarding psychiatric illness (that is, attribution of symptoms, awareness of illness, and need for treatment). We administered the Personal Beliefs About Illness Questionnaire (PBIQ) (5) to obtain patients’ current beliefs about their illness and the degree to which patients felt that the social and scientific beliefs about their illness reflect statements about themselves. The PBIQ assesses beliefs about control over the psychotic illness; about the perception of the self as illness; and about expectations, stigma, and social containment. Both scales have good test–retest reliability and validity (4,5).
Overall, individual patients were knowledgeable about their illness: 90% answered correctly on at least 75% of the items. Good knowledge was significantly associated with good insight about the psychotic illness (P < 0.05). However, having good knowledge about the facts of the illness was not related to individuals’ beliefs about the illness. Further, those who demonstrated good insight did not necessarily demonstrate positive beliefs about the illness. Pearson correlational analyses revealed that those demonstrating good insight endorsed items on the PBIQ that suggested lack of control over the illness (P < 0.001), expectations of requiring care for the illness (P < 0.01), experiences of stigma (P < 0.05), and the need for social containment (P < 0.05).
These data imply that offering education to individuals with psychosis, even when they demonstrate good insight into the illness, may not be enough. Rather, these data support the need to understand and address the beliefs individuals hold about their psychosis—beliefs that tend to reflect negative statements about themselves. Such beliefs may lead to secondary morbidity following illness onset. Recent support for cognitive-behavioural therapy (CBT) with first-episode subjects (6) implies that CBT may be an appropriate intervention to help challenge some of the personal beliefs that may impact negatively on outcome.
References
1. Albiston D, Carbone S, Cowling V, Francey S, Haines S, McGrath P, and others. Psychoeducation in early psychosis. Victoria (Australia): Promotions Unit, Department of Human Services; 1997. p 1–13.
2. Addington J, Addington D. Early intervention for psychosis: The Calgary early psychosis treatment and prevention program. CPA Bulletin 2001;33:1–6.
3. Barraclough C, Tarrier N, Watts S, Vaughn C, Bamrah J, Freeman H. Assessing the functional value of relatives’ knowledge about schizophrenia. A preliminary report. Br J Psychiatry 1987;151:1–8.
4. Birchwood M, Smith J, Drury V, Healy J, MacMillan F, Slade M. A self-report insight scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatr Scand 1994;89:62–7.
5. Birchwood M, Mason R, MacMillan F, Healy J. Depression, demoralization and control over psychotic illness: a comparison of depressed and non-depressed patients with a chronic psychosis. Psychol Med 1993;23:387–95.
6. Sensky T, Tukington T, Kingdon D, and others. A randomized controlled trial of cognitive behavior therapy for persistent positive symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry 2000;57:165–73.
Laura Quillams,
BA Calgary, Alberta
Jean Addington, PhD
Toronto, Ontario
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