INSIGHT

Dr Ashish Debsikdar
Resident-

Insight: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 AhaErlebnis.

-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 ones own condition. (mental illness)

It refers to:the conscious awareness and understanding of ones

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.

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 ones mental illness.
{The term was coined by Babinski in 1914, usually
confined to a syndrome following lesions in the right

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

ones own state of mind, ones motivations and
actions, or ones relationship to others.

INSIGHT

1. Self appraisal and

self

JUDGMENT

esteem
1. Appraisal of major

2. Understanding of

social relationships

the current
circumstances
2. Understanding of
3. Ability to describe

personal,
psychological and
physical status.

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 firstepisode 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.

Relationships Between Symptom Pathology

and 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.

ConclusionDifferent 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 SAssessment 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 patients 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 patients 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 7point 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,
delusional interpretation of hospitalization, and lack of
cooperation with treatment staff.

-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

Schedule for the Assessment

of Insight (SAI)
David et al 1990
-Using a semi structured interview, the SAI scores the patients
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 patients 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 patients
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 patients agreement with the
assessment of illness and the treatment plan as laid
out by the psychiatric treatment team.
-The psychiatrists understanding of the patients
illness is viewed as the ideal and the patients
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 Appelbaums 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 Patients Experience of

Hospitalization (PEH)
-The PEH scale focuses on a hospitalized patients 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 4point 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 you think
you have a condition that . . . ?)

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

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.

The Beck Cognitive Insight Scale

(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 patients capacity to evaluate his
unusual experiences.

Drawing on principles of cognitive-behavioral therapy, the BCIS

sees inability to distance oneself from distortions (lack of selfreflectiveness) 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 Markov 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 patients awareness of the changes

in subjective experience that occur with psychosis (selfknowledge) 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.

MANAGEMENT

Pharmacological Standpoint:-Clozapine is the only medication reported in literature

to have a substantial effect on patient insight (Pallanti
et al, 1999).

-It was suggested 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 multifaceted 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.

Erik
Erikson

Erik H. Erikson. Insight and

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 farreaching 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 VIGNETTES

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.
Im not bipolar. Everybody has mood swings! he
insisted. He added, I will take the medications while I

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 dont
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
embraced her real mother.

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?

THANK
YOU