Daniel C. Mograbi

On the Relation among Mood, Apathy, and Anosognosia in Alzheimer's Disease

This review explores the relationships between depression, apathy, and anosognosia in Alzheimers disease. Depressed mood is found to be associated with less anosognosia, while greater apathy is associated with more anosognosia, and the contrasting reasons for these associations are discussed. The review also describes recent research findings indicating a dissociation between impaired awareness of condition/deficit and preserved emotional reactivity in response to illness-related material or the experience of failure in tests. We conclude by pointing to future directions for this area of research and clinical implications.

Implicit awareness in anosognosia: Clinical observations, experimental evidence, and theoretical implications

Unawareness of deficits caused by brain damage or neurodegeneration, termed anosognosia, has been demonstrated in a number of different neurological conditions. Clinical observation suggests that unawareness paradoxically can be accompanied by signs of understanding or representation of deficit, but not explicitly expressed. Such “implicit awareness,” an apparent oxymoron, is implied by or inferred from actions or statements of the person with neurological disorder. In the current paper, we review clinical observations and experimental evidence which suggest the occurrence of implicit awareness in dementia and hemiplegia, and explore the clinical and theoretical implications of this phenomenon. We present a theoretical framework to understand implicit awareness in these two conditions.

Awareness of Disease in Dementia: Factor Structure of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia

Despite the growing understanding of the conceptual complexity of awareness, there currently exists no instrument for assessing different domains of awareness in dementia. In the current study, the psychometric properties of a multidimensional awareness scale, the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia (ASPIDD), are explored in a sample of 201 people with dementia and their family caregivers. Cronbachs alpha was high (α = 0.87), indicating excellent internal consistency. The mean of corrected item-total correlation coefficients was moderate. ASPIDD presented a four-factor solution with a well-defined structure: awareness of activities of daily living, cognitive functioning and health condition, emotional state, and social functioning and relationships. Functional disability was positively correlated with total ASPIDD, unawareness of activities of daily living, cognitive functioning, and with emotional state. Caregiver burden was correlated with total ASPIDD scores and unawareness of cognitive functioning. The results suggest that ASPIDD is indeed a multidimensional scale, providing a reliable measure of awareness of disease in dementia. Further studies should explore the risk factors associated with different dimensions of awareness in dementia.

Effect of unawareness on rehabilitation outcome in a randomised controlled trial of multicomponent intervention for patients with mild Alzheimer's disease

Unawareness of deficit has been shown to affect the outcome of targeted cognitive intervention programmes applied to patients with Alzheimer’ disease (AD), but the effects on multimodal therapeutic approaches have not yet been explored. This research investigated the efficacy of the Multi-Intervention Programme (MIP) approach on improving cognitive, functional, affective, and behavioural symptoms in people with mild AD. In addition, we examined whether the presence of unawareness influences the MIP outcomes. Sixty-one mild stage AD patients were randomly assigned to either an experimental group which carried out an MIP individually (48 sessions, 16 weeks duration), combining diverse cognitive tasks, training in daily life and recreational activities, or a waiting list group which did not receive any treatment for the same time period. The efficacy of MIP (vs. waiting list) was tested using various standardised neuropsychological, functional, and behavioural outcome measures. Planned analyses were carried out to determine the effect of unawareness versus awareness on such outcomes. The results showed that patients overall benefited from the MIP in terms of both cognitive and non-cognitive symptoms. AD patients with awareness of deficits showed positive effects on all outcome measures in comparison with the waiting list group, while AD patients with unawareness showed improvements in non-cognitive symptoms only. In conclusion, the presence of unawareness reduces the cognitive and functional effects of MIP in patients with mild AD.

Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia

BACKGROUND Some studies indicate that mood self-assessment is more severely impaired in patients with bipolar disorder in a manic episode than in depression. OBJECTIVES To investigate variations in mood self-assessment in relation to current affective state in a group of individuals with bipolar disorder. METHODS A total of 165 patients with a diagnosis of bipolar disorder type I or type II had their affective state assessed using the Clinical Global Impressions Scale for use in bipolar illness (CGI-BP), the Positive and Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF). In addition, participants completed a self-report visual analog mood scale (VAMS). Patients were divided into three groups (euthymia, mania, and depression) and compared with regard to VAMS results. RESULTS Manic patients rated their mood similarly to patients in euthymia in 14 out of 16 items in the VAMS. By contrast, depressed patients rated only two items similarly to euthymic patients. CONCLUSION Patients with bipolar disorder in mania, but not those in depression, poorly evaluate their affective state, reinforcing the occurrence of insight impairment in the manic syndrome.

Emotional Reactivity to Film Material in Alzheimer’s Disease

Aims: To explore emotional reactivity in mild to moderate Alzheimer’s disease (AD) using film material, investigating the influence of dementia-related material and awareness of condition. Methods: Twenty-two patients with AD and 21 healthy older adults viewed films with positive, neutral or negative content, including a film about dementia. Reactivity was measured through a self-report questionnaire and filming of facial expressions. Awareness of condition was assessed contrasting patients’ versus informants’ versions of an anosognosia questionnaire. Results: The AD patients showed reduced self-reported reactivity to negative films, but exhibited a pattern of facial responses similar to controls for all films. Awareness was associated with frequency of negative facial expressions during the dementia film. Conclusions: AD patients may have impairments in self-reported reactivity to negative stimuli. Awareness may mediate responses to dementia-related material.

Insight in bipolar disorder: a comparison between mania, depression and euthymia using the Insight Scale for Affective Disorders

OBJECTIVE To evaluate whether having general insight into bipolar disorder and its symptoms is affected by the mood state of the patient, using the Insight Scale for Affective Disorders, a hetero-application scale for people with mood disorders. METHODS Ninety-five patients with bipolar disorder were evaluated and divided into different groups according to the mood state presented during assessment (i.e., euthymia, mania and depression). Sociodemographic and clinical data (Hamilton Depression Scale, Young Mania Rating Scale, and Clinical Global Impressions Scale) were recorded. Insight was evaluated using the Insight Scale for Affective Disorders. RESULTS Patients with bipolar disorder in mania show less insight about their condition than patients in depression or euthymia, and less insight about their symptoms than patients with depression, with the exception of awareness of weight change. CONCLUSIONS Loss of insight during mania may have important implications for treatment compliance and adherence and needs to be taken into account in the clinical management of people with bipolar disorder.

Cross-cultural adaptation, validation and factor structure of the Insight Scale for Affective Disorders

BACKGROUND In the last few decades, several tools for studying insight in bipolar disorders have been used. Olaya and colleagues developed the Insight Scale for Affective Disorders (ISAD), which consists of a scale measuring insight through hetero evaluation for patients with mood disorders. The objective of this work is to translate and adapt the original English version of the ISAD to Brazilian Portuguese (ISAD-BR) and to conduct an evaluation of its psychometric properties. METHODS Adaptation procedures included translation/back-translation and consultation with a panel of experts. 95 patients with the diagnosis of Type 1 bipolar disorder were evaluated with the final version of the ISAD-BR, which was applied, simultaneously, but independently, by two examiners. Internal consistency and inter-rater reliability were explored and the latent structure of the scale was investigated with principal axis factoring and promax rotation. A second-order factor analysis was conducted to test if the scale had a hierarchical factor structure. RESULTS The ISAD-BR showed good internal consistency and good inter-rater reliability. The analysis pointed to a four-factor solution of the ISAD-BR: awareness of symptoms associated with activity/energy; awareness of having a disorder; awareness of self-esteem and feelings of pleasure; and awareness of social functioning and relationships. The second order factor analysis indicated a hierarchical factor structure for the ISAD-BR, with the four lower-order factors loading on a single higher-order factor. CONCLUSIONS Insight into bipolar disorder is a multidimensional construct, covering different aspects of the condition and its symptomatology. Nevertheless, insight about activity/energy changes may be a crucial aspect of insight into bipolar disorder.

O insight no transtorno bipolar: uma revisão sistemática

Objectives To conduct a systematic review to understand which factors are related to insight in bipolar disorder (BD), how insight varies depending on affective state and to establish a comparison between BD and other mental disorders. Methods We performed a systematic review of the scientific literature on insight in BD patients. Clinical studies on the topic were searched in the Medline, SciELO and ISI databases. The search terms used were: “insight” OR “Awareness” AND “bipolar“ OR “mania”. Results Fifty-five articles were selected. Insight in BD is more compromised than in unipolar depression, but less than in schizophrenia. A lower level of insight is related to the presence of psychotic symptoms and cognitive disorders. Moreover, insight impairment is associated with lower adherence to treatment. On the other hand, a greater preservation of insight may be associated with increased suicidal ideation. Finally, the manic phase is characterized by a lower level of insight than the depressive phase or euthymia. Conclusion Insight is greatly impaired in BD, especially during mania. Several clinical factors seem to influence the level of insight.

The reliability of self-assessment of affective state in different phases of bipolar disorder.

Abstract Some studies have indicated that the capacity of self-assessment of affective state is more compromised during mania than during depression. In the present study, we investigated whether the reliability of self-assessment in bipolar disorder varies as a function of actual affective state (i.e., euthymia, mania, or depression). Sixty-five patients with a diagnosis of type I and type II bipolar disorder were evaluated with regard to the occurrence of an affective syndrome using the Clinical Global Impressions Scale for use in bipolar illness, the Positive and Negative Syndrome Scale, and the Global Assessment of Functioning scale. In parallel, we applied the Analog Visual Mood Scale, a self-assessment tool to evaluate mood changes. The same individual prospectively completed the self-assessment scale in different affective states. During depression, the patients’ evaluation was significantly different from when they were in manic or euthymic mood states. However, when in mania, the patients evaluated their mood state similarly to when they were euthymic. The bipolar patients in mania but not in depression did not reliably evaluate themselves with regard to their affective state.