No abstract

Less focus on the relative risk and more on the absolute risk of violence posed to society by people with schizophrenia would serve to reduce the associated stigma. Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.

SYNOPSIS The study is a prospective investigation of the factors associated with treatment compliance in 61 patients discharged from hospital with a ward diagnosis of schizophrenia. All cases were classified using reliable diagnostic criteria and all were followed up for two years. Compliance was assessed by inspection of records and by analysis of urine. Sociodemographic factors and illness variables were unrelated to compliance. Some aspects of a patient's insight and attitude, namely, a belief that medication had helped during the admission, a stated willingness to take treatment after discharge and a generally optimistic outlook, were associated with improved compliance. Other variables which showed such an association were the absence of the drug sideeffect akinesia, good previous compliance and voluntary, as opposed to compulsory, admission to hospital.

An assessment schedule was used to determine the nature of insight in 91 mixed psychotic patients, and to examine its distribution and associations. While all the components of the schedule intercorrelated significantly, scores for compliance were only weakly related to those for ability to label psychotic phenomena as abnormal. Compliance and illness recognition were related to IQ. Total insight score was inversely correlated, moderately, with a global measure of psychopathology derived from the PSE, and was less in patients involuntarily committed. Age, sex, diagnosis, and the number of previous hospital admissions had little effect. The results support the notion that insight is not a unitary concept.

Associations between delusions and abnormal behaviour were retrospectively assessed in a sample of 83 consecutively admitted deluded subjects. All were interviewed about events in the previous month using a new measure of delusional phenomenology and action. For 59 subjects this information was supplemented by informant interviews. Clinical consensus was reached concerning the probability that actions reported by informants were linked to delusions. Half of the sample reported that they had acted at least once in accordance with their delusions. Violent behaviour in response to delusions was uncommon. Information provided by informants suggested that some aspect of the actions of half of the sample was either probably or definitely congruent with the content of their delusions. However, there was no link between self-reports and informants' reports of such action. A latent class analysis of self-reported delusional action suggested three classes of action, namely aggressive to self or other, defensive action, and either none or single action. Self-reported action was associated with delusions of catastrophe. Informant data suggested that persecutory delusions were the most likely to be acted upon, but in contrast delusions of guilt or catastrophe appeared to decrease the chance of delusional behaviour. Actions associated with abnormal beliefs are more common than has been suggested.

Lack of treatment-related decisional capacity is a common but by no means inevitable correlate of admission to a psychiatric in-patient unit.

In combination with a clinical interview, the MacCAT-T can be used to produce highly reliable judgements of capacity.

The aim of the study was to identify the phenomenological characteristics of those delusions which are associated with action. The sample consisted of 79 patients admitted to a general psychiatric ward, each of whom described at least one delusional belief. The variables studied included the phenomenology of the delusions, and behaviour. Two behavioural ratings were used, one derived from the subjects' own description of their behaviour and the other from information provided by informants. There was no association between delusional phenomenology and acting on a delusion when the subjects' behaviour was described by informants. When action was described by the subjects themselves, acting was associated with: being aware of evidence which supported the belief and with having actively sought out such evidence; a tendency to reduce the conviction with which a belief was held when that belief was challenged; and with feeling sad, frightened or anxious as a consequence of the delusion.