Insight - Psychiatry

INSIGHT
Dr Ashish Debsikdar
Resident- Psychiatry

It is the understanding of a specific cause and effect in a
specific context.
It could be:-
1. A piece of information.
2. The act or result of understanding the inner nature of
things or of seeing intuitively. ( called „Noesis‟ in Greek)
3. An introspection.
4. The power of acute observation and deduction,
discernment, perception called as Intellection.

-An insight that manifests itself suddenly, such as
understanding how to solve a difficult problem, is sometimes
called by the German word “ Aha-Erlebnis”.
-This term was coined by the German psychologist and
theoretical linguist Karl Buhler.
-It is also known as an Epiphany.

Definition:-
In Psychiatry and Psychology, Insight means the
recognition of one‟s own condition. (mental illness)
It refers to:-
the conscious awareness and understanding of one‟s own
psychodynamics and symptoms of maladaptive behavior;
highly important in effecting changes in the personality and
behavior of a person.

The Beginning…
-Work on Insight was pioneered by Aubrey Lewis (1934).
-Temporarily defined as:-
“a correct attitude to morbid change in oneself”
-But warned that the words „correct‟, „attitude‟, „morbid‟ and
„change‟, each called for discussion.

-Zilboorg stated that „amongst the unclarities which are of
utmost clinical importance and which cause utmost confusion
is the term insight‟.
(Zilboorg G. The emotional problem and therapeutic role of insight, 1952)
-Post discarded it as a concept with „limited value‟.
(Post F. Clinical assessment of mental disorders, 1983)

-Freud while not employing the term specifically, realized
that what present day analysts would call insight was not
merely rational self-evaluation, otherwise simply reading texts
on psychoanalysis would cure neurosis.
-Rather, it requires an appreciation of hidden truths which
when uncovered lose their power to cause neurotic conflict.

Multi-dimensional model of Insight
By Amador and David 1998
1. Awareness that one is suffering, in a general way, from a
mental( as opposed to a physical) disturbance which
could be an illness.
2. More specific awareness that certain experiences
including beliefs and perceptions may not be veridical,
and further that they too could be a part of an illness.
3. Acknowledgement of the medical implications of the
above, a concrete token of which is informed acceptance
of treatment.

Grades of Insight:-
Gelder M, Gath D- Oxford textbook of Psychiatry. 1983
1. Complete denial of illness.
2. Slight awareness of being sick and needing help but denying it
at the same time.
3. Awareness of being sick but blaming it on others, on external
events, on medical or unknown organic factors.

4. Intellectual Insight- Admission of illness and recognition
that symptoms or failures in social judgment are due to
irrational feelings or disturbances; without applying that
knowledge to future experiences.
5. True Emotional Insight- Emotional awareness of the
motives and feelings within, of the underlying meaning of
symptoms; and whether this awareness leads to changes
in personality and future behavior, openness to new ideas
and concepts about self.

Impaired Insight-
-Diminished ability to understand the objective reality of a
situation.
-A person with very poor recognition or acknowledgement is
referred to as having „poor insight‟ or „lack of insight‟.
-The most extreme form is „ANOSOGNOSIA‟ that is the total
absence of insight into one‟s mental illness.
{The term was coined by Babinski in 1914, usually confined to a
syndrome following lesions in the right hemisphere, mainly the
parietal lobe}.

Factors influencing insight
1. Cultural models of illness
2. General intelligence and knowledge
3. Doctor-patient relationship.
4. Symptomatology (Delusions/Depression)
5. Denial- Motivation, Preservation of self esteem,
Avoidance of stigma
6. Personality- Compliance non conformity as a trait.

Relationship of Insight to Compliance
It would be very logical to assume that insight predicts
treatment compliance
McEvoy et al carried out a systematic study on 100 chronic
schizophrenic patients
-Three questions were asked- Do you think you a) had to be
in a hospital? b) had to see a psychiatrist? c) had to see a
doctor?
-Only 31 answered yes to one of these questions of which 14
adhered to their medications. Of the remaining 69, 12 took
their medications.
-So, over half of the insightful patients did not take their
medications whereas 17% of the insight less ones did!

Relationship of Insight to Compliance
In another study..( Van Putten et al 1963)
29 drug refusers and 30 drug compliers, all chronic
schizophrenic patients were examined.
Insight was determined using the WHO definition and it was
found that 7 drug refusers had insight compared to 18 of the
drug compliers.
*So, Insight though related to compliance is a rather poor
predictor of it.*

It is therefore recommended that drug
compliance and awareness of illness
be regarded as separate though
overlapping constructs which
contribute to insight.

Insight vs. Judgment
Insight denotes “ Looking-in”
Judgment denotes “ Looking-out”
Both entail processes of appraisal or assessment of one‟s
own state of mind, one‟s motivations and actions, or one‟s
relationship to others.

INSIGHT
1. Self appraisal and self
esteem
2. Understanding of the
current circumstances
3. Ability to describe
personal, psychological
and physical status.
JUDGMENT
1. Appraisal of major
social relationships
2. Understanding of
personal roles and
responsibilities.

Questions regarding patients
awareness of their own conditions, their
plans for the future and their
understanding of their own limitations
best demonstrate their insight and
judgment.

ETIOLOGY OF INSIGHT
The 3 main schools of thought regarding the etiology of
insight:-
1.The Psychological Defense Model,
2. The Cognitive Deficit Model,
3. The Neuropsychological Deficit Model

The Psychological Defense Model:-
-Practically the only existing school of thought about insight
prior to 1990.
-Assumption was that failure to recognize or admit to a
psychiatric illness was a conscious (or sub-conscious) refusal
rather than an inability. It was further assumed that
knowledge of the illness did exist at some cognitive level.
-Numerous studies (Smith et al. 2004,Weiler et al. 2000,
Carroll et al. 1999) have all noted a positive correlation
between increasing insight and increasing depression.

-Smith et al. (2004) suggest that poor insight may be a
psychodynamic coping mechanism to reduce anxiety and
depression.
-It is important for caregivers to be aware of the increasing
risk of depression that seems to occur with improving insight.

Cognitive Deficit Model:-
-Acknowledges a slightly more organic etiology to impaired
insight.
-Drawing on research that has linked decreasing insight to
increasingly poor scores on the Wisconsin Card Sorting Test
(WCST) and other measures of cognitive function (Keshavan
2004, Lele1998), the Cognitive Deficit Model suggests that
poor insight is a result of progressively degenerating
cognitive functioning over the course of the illness.
-

-Given the high frequency of poor insight seen in first-episode
schizophrenia patients (Keshavan 2004), progressive
degeneration does not seem to be a likely causal factor of
poor insight.
-However, this does not discount cognitive functions as a
correlation factor. The link between poor WCST scores
(measure of frontal lobe function), and poor insight in
schizophrenia patients may be evidence for a more
neurological basis of impaired insight

Neuropsychological Deficit Model:-
-Developed out of an identified similarity between the symptoms of
poor insight and a neurological condition called anosognosia.
-
Generally developing secondary to a specific lesion (such as focal
traumatic brain injury) or diffuse brain damage (such as a stroke),
anosognosia is an acknowledged neurological deficit.
-
Patients afflicted with anosognosia share striking similarities with
psychiatric patients who have impaired insight (Amador and Paul
2000, Lele et al.1998).
-
Both have a severe lack of awareness of their deficits, have a
strong desire to prove their own assertions, and as such invent
confabulations to explain away pathological symptoms. Also. both
sets of patients often demonstrate frontal lobe deficits.

Poor Insight:-
-One possible association is found between increased
negative symptom pathology, frontal lobe deficits, and a
general unawareness of mental illness.
-Cuesta et al (1998) found that poorer insight was associated
with more negative symptoms.
-Kemp and Lambert (1995) likewise showed that improving
negative symptom pathology has a significant correlation with
improving insight.

-However, some of the same authors (Cuesta et al. 1998,
Kemp and Lambert 1995, Amador et al. 1994) have also
found links between increasing positive symptoms and poorer
insight.
-Cuesta et al (1998) and Kemp and Lambert (1995)
specifically note that increased psychosis and grandiosity
(both positive symptoms of schizophrenia) are associated
with increased misattribution of psychiatric symptoms.
-

Components of refractoriness in
psychosis:-
1. Impairment of objectivity about the cognitive distortions.
2. Loss of ability to put these into perspective.
3. Resistance to corrective information from others.
4. Overconfidence in conclusions.

Insight in Mood Disorders:-
-Patients with bipolar disorders, investigated by the ITAQ,
showed that insight was severly impaired in mania and less
impaired in depressive states.
(Michalakeas et al 1994)
-At the time of admission, patients with mania had greater
impairment of insight than those with depression.
(Peralta and Cuesta 1998)

--Patients with seasonal affective disorders possessed a
moderate amount of insight into their depressive symptoms,
as measured by the SUMD, which did not change after
recovery.
(Ghaemi et al 1995,1997)
-Insight may also be impaired at times in the neurotic states,
like OCD ( Eisen et al, 1994) and Anorexia nervosa ( Feighner et
al 1972)

Some studies/articles
and their salient points.

Insight in Psychosis: relationship with
Neurocognition, Social cognition and Clinical
symptoms depends on the phase of illness
Piotr J. Quee et. al. – University Medical Center Groningen,
Netherlands.
Published in Schizophrenia Bulletin Vol. 37, in 2011.

Insight can be studied as a set of descriptive beliefs and as a
personal narrative, under 3 dimensions.
1. The recognition that one has a mental illness.
2. The recognition of the need for treatment.
3. The ability to relabel unusual mental events ( delusions
and hallucinations) as pathological.

Neurocognitive domains like reasoning and problem
solving, verbal learning and memory have been found to
predict reduced insight in patients with psychosis.
Social cognition- referred to as „the ability to construct
representations of the relations between oneself and others
and to use those representations flexibly to guide social
behavior‟.
The clinical symptoms (positive symptoms, negative
symptoms and disorganization) have also been found out to
be good predictors of the degree of insight.

•This study was part of the large scale Genetic Risk and
Outcome of Psychosis study (GROUP).
•Composite measures were created for insight,
neurocognition, social cognition and clinical symptoms.
•270 patients with psychotic disorders were included after
they met the eligibility criteria. 2 groups:-
•ROP- (Recent onset psychosis)- 1 psychotic episode in the
year prior to assessment.
•MECP- (Multiple episode or chronic psychosis)- Illness
duration of more than 1 year or of multiple psychotic
episodes.

Insight was assessed using:-
1. A semi structured interview, PANSS- item on Insight
(G12)
2. Birchwood Insight Scale (BIS):-
- Short Questionnaire
-- 8 questions addressing the 3 components of insight
(Need for treatment, Awareness of Illness and Relabeling of
Symptoms)
-rating on a scale of 0-4, a higher score implies better insight.

•Neurocognitive domains were assessed using the Wechsler
Adult Intelligence Scale-III. (WAIS III)
•Social Cognitive task concerning Emotion Perception was
assessed using the Degraded Facial Affect Recognition Task
and that concerning Theory of Mind was assessed using the
Hinting Task. (ability of subjects to infer the real intentions
behind indirect speech utterances).
•The Clinical Symptoms and their severity was assessed
using PANSS.

Results of the Study:-
Phase of illness was found to moderate the relation between
insight and the studied predictors.
In patients with MECP, both social cognition and clinical
symptoms had additional effects and explained insight, along
with neurocognition.
In patients with ROP, none of the factors were found to be
associated with insight. ( Relatively unstable and evolving
period, aware of their distress but not able to attribute it to a
mental disorder).

Insight into Schizophrenia: a comparative
study between patients and family members
Cross-sectional study carried out at the Institute of
Psychiatry, Sao Paulo, Brazil.
Conclusion-
Different dimensions of insight are not equally influenced by
disease and socio-cultural factors. The recognition of illness
is more strongly influenced by socio-cultural factors than the
ability to relabel psychotic phenomena as abnormal.

Amador XF, Strauss DH, Yale S- Assessment
of insight in Psychosis, Am J Psychiatry,
1993
Lack of Insight has been correlated with:-
-Worse outcomes,
-More admissions
-Worse Psycho-social functioning,
-Reduced success rates in outpatient treatment of relapses,
-Longer intervals between onset of symptoms and seeking
treatment.

White R, Bebbington P- The Social Context
of Insight in Schizophrenia, Psych.
Epidemiol. 1993
Found a strong association between the size of the primary
group( family and close friends) and insight.
Broader social contact exerts a normalizing function on the
individual that leads to better insight.

Johnson S, Orrel M. Insight and Psychosis, a
social perspective, Psychol Med. 1995
Psychotic patients disagree with their doctors as to their
symptoms and illness not only because they are ill, but
also because they have a different concept of their
experience, which is molded by their socio-cultural
context.

Standardized insight
rating scales

-Standardized scales of insight have been used in the
research setting but are not currently used in common clinical
practice.
-Scales are widely used to evaluate levels of insight across
various stages of illness, because insight correlates with
treatment outcomes.
-Although too time-consuming to administer to every patient,
a well-chosen insight rating scale could be useful for formally
documenting a patient‟s insight deficits.
-Even informally, awareness of the types of questions found
on these scales allows a more meaningful assessment of
insight.

-Sanz and colleagues14 concluded that there are
considerable correlations among the scales; this indicates the
construct validity of the concept of insight.
-Myriad of rating scales are available with which to assess a
patient‟s insight. The following 7 scales may be useful on the
acute psychiatric unit.

Item G12. Part of the General
Psychopathology section of PANSS.
-Item G12 (lack of judgment and insight), is used separately
as an insight scale.
-The PANSS was developed for use in patients with
schizophrenia, and it measures severity of illness and
subsequent improvement in trials of new antipsychotic
medications.
-Similar to the other PANSS items, Item G12 is rated on a 7-
point scale ranging from “Absent” to “Extreme.”
“Mild” applies to patients who recognize their illness but
downplay its seriousness and the need for ongoing
treatment.
“Extreme” applies to patients with blank denial of illness,

-Item G12 is closely tied to awareness/acknowledgment of
psychiatric illness and the need for treatment.
Although formally validated in patients with schizophrenia, the
anchor points of item G12 can also describe other psychotic
illnesses, including severe manic states.
-While Item G12 provides brevity and ease of administration,
it is neither comprehensive nor practical.
*However, because it is so brief, this scale could be used at
several points during an inpatient admission as a gauge of
improvement in insight during the course of treatment*

Schedule for the Assessment of
Insight (SAI)
David et al 1990
-Using a semi structured interview, the SAI scores the patient‟s
insight along 3 dimensions:
recognition of illness, recognition of need for treatment, and ability
to see that psychotic symptoms (delusions/hallucinations) are not
“real” but rather part of the illness.
-As such, it is also particularly useful in psychotic patients. Using
this approach, a psychiatrist might ask questions related to the
patient‟s interpretation of his psychosis as part of an assessment of
insight: “Mr. A, do you think your voices are coming from a real
person or place, or are they related to your illness?”

Expanded version of the SAI (SAI-E)
Items are added to more fully address the patient‟s
awareness of change, practical problems, and symptoms.
The original, with 8 items, lends itself to relatively efficient use
on the inpatient unit. The longer update is likely a bit unwieldy
for day-to-day use but may be appropriate if closer
examination is needed.

The Insight and Treatment Attitudes
Questionnaire (ITAQ)
-Developed by McEvoy and colleagues
-ITAQ has 11 questions, each scored between 0 (no insight)
and 2 (maximum insight).
-The ITAQ focuses on the patient‟s agreement with the
assessment of illness and the treatment plan as laid out by
the psychiatric treatment team.
-The psychiatrist‟s understanding of the patient‟s illness is
viewed as the “ideal” and the patient‟s degree of congruence
with this determines the level of insight.

Consultation-liaison psychiatrists may recognize that the
concept underlying this approach is similar to that of
Appelbaum‟s assessment of capacity, in which patients are
asked to explain their understanding of the rationale for a
given medical procedure and the reasoning behind their
refusal of such.
Specifically, this scale would be especially useful in
documenting the extent to which the patient agrees with the
treatment plan. This domain is increasingly important
because of the close scrutiny of third-party payers
(sometimes on a daily basis) and the growing emphasis on
patient-centered care.

The Patient’s Experience of
Hospitalization (PEH)
-The PEH scale focuses on a hospitalized patient‟s position
on a continuum from denial of illness to acknowledgment of
illness.
-This component of insight is highly correlated with treatment
adherence.
-The PEH is an 18-item self-report questionnaire that uses a
4-point scale. It is not too unwieldy for occasional use on an
inpatient unit.
(In addition, many of the items can be rephrased as
questions and used in the initial clinical evaluation or
subsequent progress notes; for example, Item 16: “I think my
condition requires psychiatric treatment” rephrased as “Do

The Scale to Assess Unawareness of Mental
Disorder (SUMD)
-Amador et al 1994. it assesses:-
1. Awareness of the mental disorder
2. Consequences of the mental disorder
3. Effects of medication
4. Hallucinatory experiences
5. Delusions
6. Thought disorder
7. Flat or Blunted Affect
8. Anhedonia
9. Asocialty

SUMD
Each of these is rated on a 4 point rating scale
0- not applicable
1-aware
2-somewhat aware
3- severly unaware
The SUMD is not summed to calculate a total score, but each
item is considered to represent a separate aspect of insight.
The interrater intraclass correlation coefficients for the SUMD
ranged from 0.76 to 0.99 with a median of 0.89

The SUMD has been validated in schizophrenia and
schizoaffective disorder and uses a structured interview
administered by trained raters.
However, the complexity of the SUMD, when administered in
its entirety, limits its practical application in non-research
situations. Fortunately, there is an array of studies in which
the SUMD was abridged to fit the needs of specific research
protocols.

(BCIS).
The BCIS is a 15-item self-report questionnaire in which patients
are asked to rate the degree of their agreement with specific
statements.
In contrast to other insight scales that focus on awareness of
illness, the BCIS assesses the patient‟s capacity to evaluate his
unusual experiences.
Drawing on principles of cognitive-behavioral therapy, the BCIS
sees inability to distance oneself from distortions (lack of self-
reflectiveness) and difficulty in accepting corrective feedback (self-
certainty) as fundamental issues in psychosis.
As with the PEH, the primary advantage of the BCIS is that it is self-
administered. It also has been validated over a variety of diagnostic
categories.

The Insight Scale (IS)
The IS, developed by Marková and colleagues in its most recent
form, is a self-report instrument validated for use with patients with
schizophrenia.
The IS consists of 30 “yes/no” items that are scored as 1 for insight
and 0 for no insight, yielding a maximum score of 30.
The IS items focus on the patient‟s awareness of the changes in
subjective experience that occur with psychosis (self-knowledge)
and how these changes might affect his interactions and functioning
within his environment.
The primary limitation of this scale on an inpatient psychiatric unit is
the exclusion of items related to the need for treatment.

Pharmacological Standpoint:-
-Clozapine is the only medication reported in literature to
have a substantial effect on patient insight (Pallanti et al,
1999).
-It wassuggested that clozapine might improve frontal lobe
processing through early gene expression, which correlates
with previous research findings indicating that clozapine
improves WCST scores in schizophrenia patients (Schall et al,
1995), and that poor WCST scores are an indicator of impaired
insight (Keshavan et al. 2004,Young et al. 1993).
-However, Pallanti et al. also point out that clozapine may
indirectly improve insight by improving negative symptom
pathology, which in turn might make patients more amenable
to psychosocial intervention programs.

Psychosocial Interventions:-
-Rickelman (2004) states that good insight in schizophrenia
patients is related to a strong social support network.
-Interventions such as vocational rehabilitation (Lysaker and
Bell, 1995), and a specifically modified form of motivational
interviewing (Rusch and Corrigan, 2002) have shown some
success.
-Thompson et al. (2001) noted that "improving insight" may
be due to the socialization and education of a person as a
schizophrenia patient (i.e. their exposure to hospital
programs and diagnostic labels), or to their improving ability
to communicate about their illness.

Insight Oriented Psychotherapy:-
Insight therapy or insight orientated psychotherapy are general
terms used to describe a group of therapies that assume that a
person's behavior, thoughts, and emotions become disordered
because they do not understand what motivates them.
The theory of insight therapy, therefore, is that a greater
awareness of motivation will result in an increase in control and
an improvement in thought, emotion, and behavior.
The goal of these therapy is to help an individual discover the
reasons and motivation for their behavior, feelings, and thinking
so that they may make appropriate changes.
These therapies may all be described as insight orientated:
psychoanalysis, analytical psychology psychodynamic therapy
person-centered therapy.

Cognitive Behavior Therapy:-
CBT is one specific form of psychosocial treatment that has
recently shown some promising results.
Goldapple et al. (2004) showed that CBT can alter metabolic
brain functions in subjects with major depression.
These findings indicate not only that CBT has specific
functional effects on the brain, but also that a clinically
successful outcome may be achieved through several distinct
methods.
This is promising for the treatment of insight in schizophrenia
patients, not only because insight is a multi-faceted deficit,
but also because individuals with unique case histories,
lifestyles, and socio-economic standings may require different
treatment interventions for a positive outcome.

Given that inequitable distribution is still a black
mark on healthcare in this country (due to economic
factors, isolated geography, and lack of adequate
facilities and practitioners), cheaper and/or more
accessible options like psychosocial interventions
may be able to reach a greater number of people in
need.

Pseudo-insight
-Jaspers stated that listening to a patients utterances out of
context can lead to mistaken judgments about the presence
of insight.
-Patients may acknowledge „morbid change‟ but this is not
sufficient to be considered insightful.
--With Pseudo-insight the patient merely regurgitates
overheard explanations.
-As mentioned, Insight requires the acceptance of a personal
illness affecting the mental apparatus, whose etiology may be
unknown.

Researchers and caregivers must be careful with
their definitions of insight, and be aware that their
own selective biases and medical vocabulary can
limit what they see as good or poor awareness.
As Rusch and Corrigan (2002) pointed out, what is
considered good insight in a clinical or research
setting may simply be the patient agreeing with the
health professional's opinions.

Responsibility.(1969)
-Collection of his lectures in which he identifies concepts and
explains principles that give deeper insight into human
behavior.
-He states that each generation leaves on the pages of
history a record of the conflict existing between its nature of
growth from childhood to adulthood and its ethical and
rational aims.
-Observed that a failure to develop basic trust and mutuality,
a relationship on which partners depend upon each other for
the development of their basic strengths, is recognized in
psychiatry as a far-reaching failure, which delays
development.

-In the 2nd chapter of his book- “Nature of Clinical Evidence”,
he explains the role of a psychotherapist in helping the
patients to gain identity.
-In his 3rd chapter “Identity and Up rootedness in our time” he
moves from observing individuals to applying insight to
people uprooted by historical fate.
-He closes by assigning to the next generation the task of
integrating new and old methods of understanding self, or
self awareness, with technical proficiency.

Case Vignette 1
Mr. A, a 20-year-old college student, was involuntarily
admitted to the psychiatric inpatient unit in a florid manic
state, with rapid speech, flight of ideas, and sleeplessness.
Before admission, he had been clocked driving at 100 mph.
The intercepting police, noting his abnormal mental status,
brought A to the emergency department.
Mood stabilizer and antipsychotic medication settled him over
a week, but he still persisted in believing the police “must
have been drunk themselves,” since they assessed him as
needing psychiatric help.
“I‟m not bipolar. Everybody has mood swings!” he insisted.
He added, “I will take the medications while I am here, but I
am not sure I really need them after I leave.”

Mr. A clearly does not accept the bipolar disorder diagnosis.
Is this part of his illness and a sign that he is not yet stable?
Should we trust him in a partial hospital or outpatient program
or should he remain on a locked inpatient unit?
In view of his lack of insight, does he need a change of
medication? What should his family be told about his
prognosis, especially if he persists in his denial of illness?
Understanding insight is paramount for answering these
questions.

Case Vignette 2
Ms J, a 27-year-old with schizophrenia, stopped taking her
prescribed antipsychotic consistently. Within 2 months, her
psychotic symptoms returned with full force, and she required
hospitalization.
She told the admitting psychiatrist that the woman who
brought her to the emergency department was not her real
mother, but rather “an actress playing her mother.” This
misperception had likely played a role in threats she had
made toward her mother on the day of admission.
Questioned by the psychiatrist as to the plausibility of
someone resembling her mother so precisely, she
responded, “I don‟t know how they did it, but somehow they
were able to find someone!”
A week after restarting her medication, Janice allowed that
her imagination had been “playing tricks on her” and happily

How much of an insight does Ms J have into her illness?
Is she ready to go home after her week in the hospital?
Does she really understand her illness well enough to be
allowed to manage her own medications again?
Does the risk of violence change the assessment?
Should a long-acting injection be prescribed, given her history
of nonadherence?

Insight - Psychiatry

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