First- and Third-Person Perspectives in Psychotic Disorders and Mood Disorders with Psychotic Features

Hindawi Publishing Corporation Schizophrenia Research and Treatment Volume 2011, Article ID 769136, 5 pages doi:10.1155/2011/769136 Clinical Study First- and Third-Person Perspectives in Psychotic Disorders and Mood Disorders with Psychotic Features Lucrezia Islam, Silvio Scarone, and Orsola Gambini Psychiatric Branch, Department of Medicine, Dentistry and Surgery, University of Milan Medical School, San Paolo Hospital, Via Antonio di Rudinı̀ 8, 20142 Milan, Italy Correspondence should be addressed to Lucrezia Islam, Received 20 December 2009; Revised 27 May 2010; Accepted 14 July 2010 Academic Editor: Veena Kumari Copyright © 2011 Lucrezia Islam et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lack of insight, very frequent in schizophrenia, can be considered a deficit in Theory of Mind (ToM) performances, and is also found in other psychiatric disorders. In this study, we used the first- to third-person shift to examine subjects with psychotic and psychotic mood disorders. 92 patients were evaluated with SANS and SAPS scales and asked to talk about their delusions. They were asked to state whether they thought what they said was believable for them and for the interviewer. Two weeks later, 79 patients listened to a tape where their delusion was reenacted by two actors and were asked the same two questions. Some patients gained insight when using third-person perspective. These patients had lower SAPS scores, a lower score on SAPS item on delusions, and significant improvement in their SAPS delusion score at the second interview. Better insight was not related to a specific diagnostic group. 1. Introduction Patients suffering from schizophrenia are incapable of recognizing and monitoring the self or nonself induced character of their own thoughts. This monitoring capacity, which separates self-generated and world-generated perception, is very important to distinguish between imagination and normal perceptions. If this monitoring capacity is disturbed, self-induced perception is experienced as world-induced [1]. There is increased evidence that patients with schizophrenia have difficulties in social cognition which requires sophisticated judgements about other people’s mental states. People with schizophrenia have worse performance profiles in tasks that require the interpretation of social inferences underlying indirect speech. Frith and collaborators, first applied the Theory of Mind deficit hypothesis to schizophrenic patients, and since then many studies have attempted to define the concept in a way that could be tested experimentally [2–4]. It has been suggested that some paranoid symptoms and behavioural signs could be a consequence of difficulties in making inferences about the intentions and beliefs of others [5]. Many clinical schizophrenic symptoms can be reinterpreted as a disturbance of the “self-monitoring capacity.” Impaired monitoring ability in schizophrenic patients can lead to serious problems in understanding subtle, context-dependent changes in the content and significance of communication [6]. Lack of insight is a common symptom in schizophrenia and can be considered a critical manifestation of impaired ToM abilities. Insight in schizophrenia is operationally defined according to five dimensions which include the patient’s awareness of mental disorder, awareness of the social consequences of disorder, awareness of the need of treatment, awareness of symptoms, and attribution of symptoms to disorder [7, 8]. Following these criteria, the lack of insight can be considered an aspect of an impaired selfmonitoring capacity. Lack of insight is not only found in schizophrenia, but can also be found in other psychotic disorders and in psychotic mood disorders [9–12]. Neurocognitive deficits have been described both in schizophrenia and mood disorders, and have been proposed to reflect underlying neurobiological dysfunction [13]. 2 The lack of awareness of illness is not specific for psychiatric patients and can be found also in neurological patients. An example is emi-neglect syndrome, in which anosognosia for hemiplegia and lack of awareness of illness are fundamental symptoms. In their studies [14, 15], Tegner and Marcel asked anosognosic hemiplegic patients about their performances with their paralyzed limbs. The patients described their limbs as normal. However, if the authors asked the same patients, “If my arm was paralyzed, could I shuffle a pack of cards?” some of the patients responded “Of course not.” These results indicate that in some cases, the passage from a first-person to a third-person perspective can change the patient’s awareness about his/her illness. We have previously hypothesized [16] that this phenomenon could be a particular aspect of a Theory of Mind task and have shown that 30 schizophrenic delusional inpatients modified their opinion about their delusions shifting from the first to the third person. In the current study, we have evaluated 92 patients with psychotic and psychotic mood disorders using first- to thirdperson shift. This task resembles the ToM second-order stories. Our hypothesis was that patients should gain insight and self-monitoring capacity when listening to their own delusions presented in a neutral context. 2. Subjects 92 (35 women, 57 men) patients participated in the study. Patients were recruited from the inpatient service of the Psychiatric Branch of the Department of Medicine, Surgery, and Dentistry of the University of Milan Medical School. All patients in the study had been admitted because of their acute psychotic state. Only those who volunteered and gave informed consent were included in the study. Informed consent with respect to the purposes and the procedure of the study was obtained from all subjects prior to starting the testing procedure. Diagnoses were made according to the DSM-IV-TR criteria by the authors (S. Scarone and O. Gambini). 69 subjects had a diagnosis of schizophrenia (21 undifferentiated, 48 paranoid), 7 had a diagnosis of psychotic mood disorder (6 of Bipolar Disorder, 1 of Delusional Depression), and 16 subjects had a diagnosis of other psychotic disorders (9 of Psychosis not otherwise specified, 2 of Schizoaffective disorder, and 5 of Delusional Disorders). Inclusion criteria were one of the previously cited diagnoses and the presence of delusions. Exclusion criteria were organic illnesses involving the central nervous system, current substance abuse and/or past and current alcohol dependence, and clinical evidence of mental retardation. Subjects were asked to participate during the first part of their inpatient stay. All patients were on antipsychotic medication at the time of our study. 25% of them were receiving 1st generation antipsychotics (10% were taking oral medication and 90% were receiving long actin (...truncated)