Ivana S. Marková

Awareness in dementia: A review of assessment methods and measures.

A comprehensive range of literature on awareness in dementia published in peer-reviewed journals during the last 15 years was reviewed with the aim of extracting details of the methods and measurement instruments adopted for the purposes of assessing awareness. Assessment approaches fell into five categories: clinician rating methods, questionnaire-based methods, performance-based methods, phenomenological methods, and multidimensional or combined methods. Ranges of objects of awareness assessment were identified both within and across domains. Strengths and limitations of methods in each category were identified. Reasons for the inconclusive findings from research using the methods described here were considered, and suggestions for future directions were made.

Psychiatric symptoms in neurologically asymptomatic Huntington's disease gene carriers: a comparison with gene negative at risk subjects.

Objective: Psychiatric profiles of two at‐risk groups [Huntingtons disease (HD) gene carriers and non‐carriers] were compared by means of a computerized battery and a structured interview.

The influence of psychological, social and contextual factors on the expression and measurement of awareness in early-stage dementia: testing a biopsychosocial model

Insufficient attention has been paid to the influence of psychological and social factors on discrepancy‐based measures of awareness.

Insight in clinical psychiatry. A new model.

Recent interest in insight in psychiatry has resulted in studies focusing on correlations between insight and variables such as severity of psychopathology, neuropsychological impairments, and magnetic resonance imaging. However, there has been relatively little exploration of the concept of insight itself as a basis of empirical research. This paper examines the concept of insight, differentiating this from the phenomenon of insight, and proposes that insight is a construct that needs to be considered from the perspective of the patient, of the clinician, and of their interaction. A new hierarchical model of insight construction is described, closely linked to symptom formation, and mechanisms are suggested to explain insight structure in relation to the different ways symptoms arise. The relationship between insight and symptom structure and disease suggests that the phenomenon of insight will vary in relation to different diseases. This in turn suggests that insight assessments should be modified according to the individual disease.

The 'object' of insight assessment: Relationship to insight 'structure'

Insight is a relational or ‘intentional’ concept, i.e., it is only understood in terms of its relation to something; and that ‘something’ is the ‘object’ of insight. In clinical practice, the ‘object’ of insight thus generally refers to a particular mental or physical state (e.g., mental illness, neuropsychological deficit) in relation to which insight is being assessed. It is argued in this paper that the ‘object’ of insight plays a crucial role in shaping or determining the sort of insight that is elicited in clinical practice (i.e., the phenomenon of insight). Three ways in which the ‘object’ of insight can shape the clinical phenomenon of insight are discussed. One concerns the conceptual background in which the ‘object’ is embedded and which is likely to impose a similar structure onto the phenomenon of insight. Another is the semantic category to which the ‘object’ of insight belongs and which will imprint its particular structure on the phenomenon of insight. Yet another concerns the specific nature of the ‘object’ which itself will shape the insight phenomenon elicited. This carries implications for research on insight, since insight tends to be explored in relation to a variety of ‘objects’. Phenomena of insight in relation to different ‘objects’ are likely to vary in structure, and this, in turn, has consequences for mechanisms underlying insight in each case. Understanding more about the nature and contribution of the ‘object’ of insight in the insight-‘object’ relationship will help to delineate separate insight phenomena and achieve consistency in empirical studies on insight.

Awareness in dementia: conceptual issues.

There has been a recent proliferation of studies exploring awareness in people with dementia and, as is the case with similar studies in other clinical areas, results are generally mixed and inconsistent. One of the reasons underlying variability in study results relates to the complexities around the concept of awareness itself. Two sources of conceptual problems are explored. First, the meaning of awareness is examined and, within the dementia literature, various conceptualizations of awareness are identified which could be traced to three broad frameworks within which awareness and related terms are conceived. Differences between meanings of awareness are thus highlighted and the importance of making such differences explicit in studies was discussed. Second, the relational aspect of awareness is raised as a crucial issue determining the phenomenon of awareness elicited in clinical practice. Thus, in dementia, awareness is related to various “objects” including the illness as a whole, memory problems, activities of daily living, affective changes and many others. In each case, however, the object of awareness will elicit a different phenomenon of awareness, again carrying implications for the generalizability of study results. Clarification of conceptual problems is essential for future work in this area in order that empirical studies can provide meaningful answers concerning the therapeutic and predictive validity of different aspects of awareness.

Psychiatric symptoms and CAG repeats in neurologically asymptomatic Huntington's disease gene carriers

The putative relationship between the psychiatric profile of a sample of neurologically asymptomatic Huntingtons disease gene carriers and CAG repeats was investigated. The psychiatric assessments (by consultant psychiatrist and computerised battery) were undertaken before the genetic testing was carried out. In this way, the informational distortions caused by neurological and cognitive deficits were avoided. The hypothesis that there is a relationship between psychiatric and CAG repeats was tested by seeking direct correlations between psychiatric systems and CAG repeats, and also by correcting the correlation by the number of years above or below the estimated age of onset in Huntingtons disease. Scores for irritability and cognitive failures were high in the sample. There was no correlation between any psychiatric variable and CAG repeats. Possible explanations for this lack of correlations are discussed.

Awareness in Alzheimer's disease and associated dementias: Theoretical framework and clinical implications

Background: Awareness can be defined as a reasonable or realistic perception or appraisal of a given aspect of ones situation, functioning or performance, or of the resulting implications, expressed explicitly or implicitly. Disturbances of awareness have significant implications for people with dementia and their caregivers. The construction of awareness has been extensively studied in dementia, but a lack of conceptual and methodological clarity in this area means that few clear findings have emerged. Aims: This article presents a framework for conceptualizing awareness in people with Alzheimers disease and associated dementias that can guide research and influence practice. Overview: This article begins by considering the general concept of awareness and the ways in which neurological damage can place constraints on awareness. Within an integrative biopsychosocial model that acknowledges the influence of neurocognitive, psychological, and social variables on awareness, challenges for empirical research on awareness in dementia are addressed, and a ‘levels of awareness’ framework is presented within which awareness operates at four levels of increasing complexity, providing a means of differentiating among awareness phenomena. Approaches to mapping awareness phenomena are discussed, and directions for future research and clinical practice are outlined. Conclusions: The levels of awareness framework should act as a stimulus to further research in this area, resulting in a more coherent understanding of the nature of awareness deficits, the implications of these for people with dementia and their caregivers, and the possibilities for targeted and effective interventions.

Longitudinal trajectories of awareness in early-stage dementia

Although it is often assumed that awareness decreases as dementia severity increases, there is limited evidence regarding changes in awareness over time. We examined awareness in 101 individuals with early-stage dementia (PwD) and their carers; 66 were reassessed after 12 months and 51 were seen again at 20 months. Awareness was assessed in relation to memory, everyday activities, and socio-emotional functioning using discrepancies between PwD and carer ratings on parallel questionnaires. PwD completed neuropsychological tests and measures of mood and quality of life. Carers completed measures of mood and stress. At initial assessment, discrepancies were greatest for activities of daily living, moderate for memory, and least pronounced for socio-emotional functioning. Discrepancy scores did not change over time. PwD self-ratings indicated perceived poorer functioning in everyday activities over time, but no change for memory and socio-emotional functioning. Carer ratings indicated perceived decline in everyday activities and socio-emotional functioning, but no change for memory. PwD declined in neuropsychological functioning, but self-ratings of depression, anxiety, and quality of life remained stable over time. Carer mood and stress levels also remained stable. At least in the earlier stages of dementia, it should not be assumed that awareness will inevitably decrease as dementia progresses.

Epistemology of Mental Symptoms

Background and Methods: Psychiatric diagnosis is dependent on the identification of mental symptoms. On the assumption that they are ‘natural kinds’, the latter are routinely entered as correlational variables in empirical research. Published work on the philosophy of psychiatry has tended to concentrate on the concept of mental disorder or on individual symptoms but has given less attention to mental symptoms as a class. This paper deals specifically with the epistemology of mental symptoms, that is, with focusing on the nature of mental symptoms as a class of ‘objects’ and how the clinician gets to know them. In order to do this, mental symptoms can be explored from various perspectives, namely: (i) as types of objects, (ii) as structures, (iii) as definitions, (iv) as pockets of meanings, (v) as comprising constituents, (vi) as attractors in specific dialogical contexts, etc. In this paper, on account of space constraints, we deal only with the former 4 perspectives. Results and Conclusion: Our analysis shows mental symptoms to be unstable constructs with implications for both correlational research and further theoretical exploration.