“ N o Estoy Enfermo ! No Necesito Ayuda! ”

www.LEAPInstitute.org

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“No Estoy Enfermo! No Necesito Ayuda!”

Ayudando a las personas con enfermedades mentales serias a aceptar tratamiento.

VIII SimposiumAbordajes Psicoterapéuticos De Los Trastornos Psiquiátricos

Cordoba, Spain, 27 March 2009

Xavier Amador, Ph.D.Columbia University

E-mail: [email protected]



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Poor Insight and relationships


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“Denial” of Illness in the News

Poor insight into schizophrenia and bipolar disorder is so common…

… news stories involving such persons appear nearly everyday.


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“Denial” of IllnessImpairs common-sense judgment about the

need for treatment…

But are we dealing with denial?

“Anosognosia”


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Unawareness of Mental Disorder

DSM IV Field Trial Study N = 221 patients with schizophrenia

Unaware 32.1%

Moderately Unaware 25.3%

Aware 40.7%

Xavier Amador, Nancy C. Andreasen, Scott Yale & Jack Gorman, Archives of General Psychiatry, 51(10):826-836, 1994


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Clinical Significance of Poor Insight

Poor Insight is associated with:

“Noncompliance” with treatment & services

Involuntary/compulsory admissions

Poorer course of illness

Criminal behavior & violence:


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Insight and Adherence

Awareness of being ill (insight) is among the top two predicators of long-term medication adherence.

What is the other top predictor?

Relationship with someone who:Listens to you without judgment.Respects your point of view.Believes you would benefit from treatment.


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DSM-IV-TRTM

Schizophrenia & other psychotic disordersXavier Amador & Michael Flaum, Co-Chairs

Page 304, American Psychiatric Association, 2000


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Anosognosia is similar• Very severe lack of awareness.

• The belief persists despite conflicting evidence.

• Confabulations are common.


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The “doctor knows best” approach does not work, because collaboration is a goal

not a given.

DO NOT expect: Gratitude Receptiveness Compliance

DO expect: Frustration and anger Suspiciousness Overt and secretive “non-compliance”

When dealing with anosognosia, or poor insight:


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Anosognosia Treatment options

• Long-acting injectable medications. But how do you convince someone to

accept?

• Motivational Interviewing and cognitive therapy


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LEAPThe Listen-Empathize-

Agree-Partner (LEAP) Approach

(Based on MAIT, Xavier Amador, Ph.D. and Aaron T. Beck, M.D.)

2000

20072008


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Double blind, randomized, controlled study of LEAP: a psychotherapy designed to improve

motivation for change, insight into schizophrenia and adherence to medication.

Céline Paillot, Ph.D. Ray Goetz, Ph.D. Xavier Amador, Ph.D.University Paris X, France, New York State Psychiatric Institute,

Columbia University Teachers College

In Press Schizophrenia Bulletin

Presentation at International Congress on Schizophrenia Research, San Diego California, April 2009


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The Problem with Antipsychotic Medications

From 50% to 75% of patients with schizophrenia exhibit full or partial non-adherence to pharmacological treatment (Rummel-Kluge, 2008).

Approximately 33% reliably take medication as prescribed (Oehl, 2000).

Within 7-10 days of medication initiation 25% are noncompliant, up to 50% after a year and up to 75% after two years (Keith & Kane, 2003).

Poor adherence found to be associated with serious negative outcomes.


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Methods54 patients diagnosed with schizophrenia were included in a six month repeated measures outpatient study.

Patients were randomly assigned to either the experimental (LEAP) or control (Roger’s) therapies and were blind to group assignment.

All patients received long acting injectable antipsychotic medications.

Blinded assessments: Insight into schizophrenia, attitudes toward treatment and motivation to change.

All assessments were made by a rater blinded to group assignment.


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Conclusions

Compared to the control psychotherapy, LEAP:

• maintained compliance to injectable antipsychotics.

• improved motivation to take medication.

• increased insight in specific areas.

• improved attitudes toward treatment.


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ListenReflectively to:DelusionsAnosognosiaDesires

Listen-Empathize-Agree-Partner


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How to delay giving your opinion:• “I promise I will answer your question. If it’s alright

with you, I would like to first hear more about ________. Okay?”

• “I will tell you what I think. I would like to keep listening to your views on this because I am learning a lot I didn’t know. Can I tell you later what I think?”

• “I will tell you. I want you to know that I think your opinion is more important than mine and I would like to learn more before I tell you what I think. Okay?



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When you finally give your opinion use the 3 A’s

APOLOGIZE “I want to apologize because my views might feel hurtful or

disappointing.”

ACKNOWLEDGE FALLIBILITY “Also, I could be wrong. I don’t know everything.”

AGREE ”I hope that we can just agree to disagree. I respect your

point of view and I hope you can respect mine.”



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EmpathizeStrategically express

empathy for:• delusional beliefs• desire to prove “not

sick!”• wish to avoid

treatment

Normalize the experienceListen-Empathize-Agree-Partner


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Agree Discuss only perceived

problems/symptoms

Review advantages and disadvantages of treatment

Reflect back and highlight the perceived benefits

AGREE TO DISAGREEListen-Empathize-Agree-Partner


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PartnerMove forward on goals

you both agree can be worked on together.



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Directions for 2009 and 2010

LEAP Institute goals

American Journal of Psychiatry Proposal for Anosognosia subtype: Xavier Amador, Ph.D., Celso Arrango, M.D. and Michael First, M.D.

Schizophrenia Bulletin Special Edition 2009Editors: Xavier Amador, Ph.D & Anthony David, M.D. - Review of efficacy of adherence therapies - Updated review of brain imaging studies - Updated review of frontal lobe findings - DSM V: Anosognosia subtype will be proposed


Documents

“ N o Estoy Enfermo ! No Necesito Ayuda! ”