Abstract

Introduction

While insight has traditionally been conceptualized as the capacity of a person to recognize his or her own illness, many psychologists and psychiatrists in their earlier years of training simplify the description of insight as whether an illness is present or absent. The concept of insight, however, is not a present-or-not entity; rather, it is a continuum. This article provides detailed accounts of the concept, briefly elucidates the history of its evolvement, lists the various definitions, and sums up different methodologies used to measure insight. The goal is to educate mental health professionals-in-training about the significance and importance of the measurement of insight in assessing the prognosis and outcome in mental illnesses.

Definition of Insight

Webster’s dictionary defines insight as: the power or act of seeing into a situation, or the act or result of apprehending the inner nature of things or of seeing intuitively. The Oxford dictionary defines it as the capacity to gain an accurate and intuitive understanding of something. An Internet search found further definitions of insight, such as clear or deep perception of a situation; the clear (and often sudden) understanding of a complex situation; grasping the inner nature of things intuitively; self-understanding; and the extent of a patient’s understanding of the origin, nature, and mechanisms of attitudes and behavior.

Historical Perspectives

The concept of insight focuses on two phenomena: the awareness of self and acceptance of mental illness, and the acceptance of a need for treatment. Freud used the term “insight” to denote knowledge of illness, but in psychoanalytic psychotherapy the term is used to denote the capacity to understand one’s own motives and be aware of previously unconscious aspects of mental activity. The development of an adequate understanding of the self is considered to be the goal of psychoanalytic treatment. In General Psychopathology,³ Jaspers described the concept of insight. According to Jaspers, the concept of insight (“the patient’s attitude”) consists of six different phenomena: understandable attitudes to the sudden onset of acute psychosis (perplexity, awareness of change); working through the effects of acute psychosis; working through the illness in chronic states; the patient’s judgment of his illness; the determination to fall ill; and the attitude to one’s own illness—its meaning and possible implications.³

According to Lewis,⁴ insight is an awareness of the morbid change in one’s self and a correct attitude to this change including, in appropriate cases, a realization that there is mental disorder. Birchwood⁵ conceptualized that insight has three components: awareness of illness, need for treatment, and attribution of illness. In the past it was customary to divide mental diseases into neurosis and psychosis by using the presence or absence of insight. This is no longer thought to be reliable or useful. There is an emerging consensus that insight is both a multidimensional and continuous construct.⁶

Assessment of Insight in Clinical Practice

The presence or absence of insight is not an all-or-nothing phenomenon, but rather a multidimensional one. People can have different levels of insight into their illness. Another common method of describing the patient’s insight is to use terms such as poor, partial, or good. However, even this is not appropriate because it fails to give justice to the various dimensions of what is believed to constitute insight. The assessment of insight should include the patient’s degree of acknowledgment of his or her illness, attitudes about having an illness, understanding of the effects of the illness on his or her current abilities and future prospects, attribution of the causes of the illness, and understanding of the need for treatment.

In their description of the insight, Gelder and colleagues⁷ assert that it is a matter of degree that is best determined by the following questions:

(A) Is the patient aware of the phenomenon that others have observed? (ie, is the patient unusually active and elated?); (B) If so, does the patient recognize the phenomenon as abnormal? (eg, maintaining that the unusual activity and cheerfulness are normal high spirits.); (C) If so, does the patient consider that they are caused by mental illness? (eg, believing that the changes observed are due to a physical illness or poison as administered by enemies.); (D) If so, does the patient think that he needs treatment?

One of the commonly accepted descriptions of the stages of insight is the one described by Sadock and Sadock in The Comprehensive Text Book of Psychiatry⁸:

Stage 1: Complete denial of illness.

Stage 2: Slight awareness of being sick and needing help but denying it at the same time.

Stage 3: Awareness of being sick but blaming it on others, on external factors, or on medical or unknown organic factors.

Stage 4: Intellectual insight. Admission of illness and recognition that symptoms or failures in social adjustments are due to irrational feelings or disturbances, without applying the knowledge to future experiences.

Stage 5: True emotional insight. Emotional awareness of the motives and feelings within and of the underlying meanings of symptoms, whether or not the awareness leads to changes in personality and behavior, openness to new ideas and concepts about self, and important people in ones’ life.

Mental illness can alter the patient’s view of the world and capacity to cope with circumstances. An assessment of insight measures the patient’s awareness of the change as well as his or her ability to adapt to change. Insight is highly complex. It is concerned with “self” and “not self” and their relatedness, and hence it is an important part of the mental status exam. Although the different staging methods described in the literature are helpful, it is best to give a description of the patient’s insight keeping in mind the different dimensions described. The descriptive method is the best method to convey the patient’s stage of insight to another person.

Measurement of Insight

Objective measures of insight should be based on the following basic assumptions: insight is a complex and multidimensional entity; the different dimensions involved in the measurement are continuous; insight can vary across different manifestations of the illness; level of insight can vary from time to time; and cultural differences can affect how a person looks at his or her illness.

The fact that insight is a multi-faceted entity has spawned the development of multiple measurement scales.

McEvoy and colleagues⁹ developed the Insight and Treatment Attitude Questionnaire (ITAQ) in 1989. The ITAQ is a semi-structured interview consisting of 11 items. Each item in the scale is scored from 0 (no insight) to 2 (good insight) and the total score is used to quantify insight. This questionnaire measures various aspects of insight such as acceptance of the presence of mental disorder (first five items) to the patient’s attitudes to medication, hospitalization and follow-up evaluation (last six items).

Birchwood and colleagues5 developed a self-report insight scale in 1994. This was based on the three dimensions described by David¹⁰: awareness of illness, need for treatment, and attribution of symptoms.

Amador and colleagues¹¹ developed the Scale for Assessment of Unawareness of Mental Disorder (SUMD) in 1993. This scale has been widely accepted as the most comprehensive of the various scales developed for the measurement of insight. This is a 20-item scale measuring the past and present awareness of having a mental disorder,  the effect of medications, the consequences of mental illness, and the awareness and attribution of the symptom items.

Each item is scored on a 6-point scale, higher scores indicating poorer insight. Insight rating is done by open-ended questions. This scale has been translated into 15 different languages and is used worldwide.

The Awareness of Illness Scale is a 7-item semi-structured interview. The first 3 items assess the recognition of having a mental illness, and the last 4 questions assess the patient’s perception of the need for psychiatric treatment. Each item is measured using a 5-point scale ranging from 1 (clear awareness) to 5 (no awareness).¹²

Insight as a Defense Mechanism

The absence of insight is often described as a defense mechanism protecting the patient from the devastating realization of his or her illness. Thus, some see it as an active effort on the part of the patient to help cope with the distress. Insight in its extreme form, denial, is a type of self deception that protects the individual from threats to the self and involves exaggerated perceptions of control and self efficacy. Much psychosocial research literature shows that such biases in cognitive appraisal of the situations are the “norm” and are not exclusive reactions to crises.¹³ A meta-analysis of 40 published studies showed that there was a positive relationship between insight and depressive symptoms in schizophrenia.¹⁴ Patients with greater unawareness of their illness had relatively less depressive symptomatology and relatively greater self-deception.¹⁵ These findings may be interpreted as evidence that poor insight serves as a defensive function.

Insight as Misattribution

Lack of insight may be viewed as misattribution, a form of cognitive error based on lack of information, systematic biases, or idiosyncratic beliefs.¹⁶ This stems from the basic assumption that there is a correct attribution for symptoms and experiences. This misattribution may not be concurrent with popular medical knowledge, but it makes sense and meaning to the patient’s inner beliefs and gives a sense of coherence and order to an otherwise unusual and chaotic experience.

Neuropsychological Model

Some have postulated that unawareness or denial of illness in psychiatric disorders stem from subtle neurological deficits associated with the disease process.¹⁷ Otherwise known as Neuropsychological Deficit Model, the development of this concept owes its origin to similarities observed between features of patients with poor insight and those described as having the neurological condition described as “anosognosia.”^18,19 Anosognosia for hemiplegia usually develops secondary to a lesion in a specific region of the brain, usually the right frontal or parietal lobes. It is shown to be present in around 50% to 60% of patients with right hemispheric stroke.²⁰ Just like poor insight has been shown to have a negative correlation with compliance and outcome in psychiatric disorders, denial of left-sided hemiplegia has been shown to be the worst prognostic factor for functional recovery from motor disorders after brain damage.²¹ However, it has not been proven that impaired functioning of any specific area could lead to lack of insight.²²

Insight and Collateral History

During his earlier years of training, one of the authors of this article interviewed a 23-year-old female patient. After spending a considerable amount of time with the patient the neo-psychiatrist determined that the patient did not have any mental illness. This issue was discussed with the patient’s relatives, who told the neo-psychiatrist that the patient kept insisting that a popular newscaster in a local television channel was her sister. The patient had mentioned the name of her sister during her evaluation, but since the clinician was not familiar with the newscaster he did not think anything of it. Upon this realization, the diagnosis changed to delusional disorder. In the same way, some aspects of the patient’s history, which may be culturally and socially different from that of the clinician, can be misattributed to a mental illness and vice versa. Therefore, taking collateral history from somebody who knows the patient well is imperative in the assessment of insight.

Insight, Outcome, and Prognosis

Help-seeking behaviors have a special place in our concept of insight, both as a dimension in itself and as an external validator.¹² Mental health professionals expect greater levels of adherence to prescribed medication regimes and outpatient treatment from persons who articulate their symptoms, recognize that these symptoms result from a mental disorder, and understand mental health care to be an appropriate intervention. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision,²³ lack of insight is common and may be one of the best predictors of poor outcome, perhaps because it predisposes the individual to noncompliance with treatment. Early insight into psychiatric symptoms, especially during the initial stage of decompensation, is known to be a predictor of good compliance and outcome in patients with schizophrenia.²⁴ In a study by McEvoy and colleagues, ITAQ scores were positively related to outpatient medication adherence and aftercare appointment attendance 30 days after discharge,⁹ and to hospital readmission at 1-year follow-up.²⁵ Ratings on the SUMD show good interrater reliability and are related to course of illness ratings as well as medication compliance ratings. Involuntary patients have been reported to have less insight.⁹ Patients with good insight are significantly less likely to be re-hospitalized and tend to be more compliant. However, these differences in outcome are complicated by the fact that some of the measures of insight are based on definitions of insight that include noncompliance. Compliance is also influenced by social and interpersonal factors and beliefs about health and sickness. If the social milieu is conducive, patients may comply with treatment even though they do not believe themselves to be ill. Insight has also been shown to improve with psychological and vocational rehabilitation.²⁶ The enhanced self-esteem from rehabilitation may underlie this improvement in insight.

Culture and Insight

Many transcultural studies of schizophrenia have found that “lack of insight” is an almost universal feature of acute and chronic schizophrenia.²⁷ Most of the studies about insight have been largely from Western countries, problems regarding the cross-cultural validity have not been adequately discussed. SUMD is the instrument that has been most used in different cultural situations around the globe, and its cross-cultural usefulness has been validated to some extent.

Insight and Violence

According to the Epidemiological Catchment Area survey, approximately 13% of schizophrenic patients engage in violent behavior.²⁸ Studies show that people with a mental illness who come from violent backgrounds are often violent themselves. A finding similar to that is found in the general population.²⁹ Violence occurs most often during acute psychotic episodes.³⁰ Because lack of insight is very common in schizophrenic patients, the predictive value of insight with regard to future violence is low. However, in an acute inpatient setting the lack of insight has been shown to have a higher predictive value for violent incidents than have other symptoms and signs.³¹

Criticism of the Concept of Insight

The concept of insight has been criticized as being simplistic and restrictive. Many believe that individuals’ perspectives, beliefs, and values should be taken into consideration when something as complex as insight is assessed. People can have various cultural frameworks to explain their illness. The misattribution theory of insight implies that there is a correct attribution for symptoms and signs. But who decides what the correct attribution is? In most cases it is decided, sometimes doubtfully, by medical authorities.²

Even a multidimensional framework for insight fails to acknowledge that people with psychiatric disorders can hold multiple beliefs about their problem that may be diverse and contradictory. Patients can simultaneously seek help from different sources which have explanatory models and treatments that contradict each other. Hence, “western” explanations (eg, disease, abnormality, infection) may coexist with “eastern” explanations (eg, supernatural causation, sin, and punishment). Such multiple models may at times be advantageous, buffering notions of loss and stigma and preventing social disintegration for the patient.

Antipsychiatrists have criticized the concept of lack of insight as a tool by which the mental health professionals label people as incapable of taking decisions regarding their health, and thereby coercing people to undergo treatment against their wishes.³²

Conclusion

Insight signifies a variety of ways in which a person’s mental life approximates itself to the beliefs of others, ie, in terms of what constitutes an illness, what beliefs are abnormal, and what medical advice it is reasonable to follow. Psychiatrists would assess and treat patients more accurately as well as enhance patient’s adherence to treatment if they had an accurate understanding of insight. The concept of insight has stimulated research into difficult theoretical and practical areas such as self-awareness and treatment compliance, respectively. Concern over a patient’s capacity for insight has the potential to humanize psychiatry.³³ Though a multitude of research has shown the significance of insight in the course, morbidity, prognosis, outcome and even mortality associated with psychiatric illnesses, the major classification systems DSM and International Classification of Diseases³⁴  have failed to incorporate the concept of insight into their classifications and definitions of illnesses. It would be greatly beneficial for patients and the professionals who work with them to have a significant understanding of the concept of insight and its implications. PP

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Dr. Basil is a resident in psychiatry, Dr. Mathews is assistant professor of psychiatry, and Dr. Sudak is associate professor of Psychiatry at Drexel University College of Medicine in Philadelphia, Pennsylvania.

Dr. Adetunji is an attending psychiatrist for MHM Correctional Services, Inc., in Philadelphia.

Disclosure: The authors report no affiliations with or financial interests in any organization that may pose a conflict of interest.

Please direct all correspondence to: Biju Basil, MD, Drexel University College of Medicine, Department of Psychiatry, Friends Hospital, 4641 Roosevelt Blvd, Philadelphia, PA 19124; Tel: 215-762-6660; Fax: 215-762-6673; E-mail: bijubasil@yahoo.com.