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“No Estoy Enfermo!
No Necesito Ayuda!”
Ayudando a las personas con enfermedades mentales serias
a aceptar tratamiento.
VIII Simposium
Abordajes Psicoterapéuticos De Los Trastornos Psiquiátricos
Cordoba, Spain, 27 March 2009
Xavier Amador, Ph.D.
Columbia University
E-mail: [email protected]
www.LEAPInstitute.org
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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…
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… news
stories
involving
such persons
appear nearly
everyday.
“Denial” of Illness
Impairs common-sense judgment about the
need for treatment…
But are we dealing with denial?
“Anosognosia”
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Unawareness of Mental Disorder
Xavier Amador, Nancy C. Andreasen, Scott Yale & Jack Gorman,
Archives of General Psychiatry, 51(10):826-836, 1994
Unaware
32.1%
Moderately Unaware
25.3%
Aware
40.7%
DSM IV Field Trial Study
N = 221 patients with schizophrenia
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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-TR
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Schizophrenia & other psychotic disorders
Xavier 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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When dealing with anosognosia, or poor insight:
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”
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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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LEAP
The Listen-EmpathizeAgree-Partner (LEAP) Approach
(Based on MAIT, Xavier Amador, Ph.D. and Aaron T. Beck, M.D.)
2000
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2007
2008
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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 (RummelKluge, 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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Methods
54 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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Listen
Reflectively to:
Delusions
Anosognosia
Desires
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Listen-Empathize-Agree-Partner
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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Listen-Empathize-Agree-Partner
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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Listen-Empathize-Agree-Partner
Empathize
Strategically express empathy for:
•
•
•
delusional beliefs
desire to prove “not sick!”
wish to avoid treatment
Normalize the experience
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Listen-Empathize-Agree-Partner
Agree

Discuss only perceived
problems/symptoms

Review advantages and
disadvantages of treatment

Reflect back and highlight the
perceived benefits
AGREE TO DISAGREE
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Listen-Empathize-Agree-Partner
Partner
Move forward on goals you
both agree can be worked
on together.
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Listen-Empathize-Agree-Partner
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 2009
Editors: 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
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Listen-Empathize-Agree-Partner