All these points above, and especially 3, 4 and 6, involve the process of insight, the knowledge of oneself with particular reference to illness. A person who becomes seriously and suddenly ill, whatever the nature of the illness, after previously having been fit for many years, is astonished by his change of health status. Such a person is likely to undergo a profound change in self and body image. He has become a person who, from being healthy and seeing illness as something that happens to other people, now sees himself as potentially frail and vulnerable. This can be personally enriching and is not necessarily a wholly negative experience.
Insight in Clinical Practice
So that she can better help her patient with a possible mental illness, the psychiatrist asks specific questions about the patient’s opinions concerning his illness. These include his degree of acknow- ledgement of illness, his attitudes to illness, his understanding of the effects of his illness on his current capabilities and future prospects. All this adds up to the assessment of insight into his condition. Insight is not an absolute; it can vary in its impairment with different facets of the condition, for example, a patient could have some limited understanding concerning his unlikelihood to obtain a job compatible with his qualifications, but virtually no understanding as to how his psychotic symptoms interfere with relationships. Thus insight is not now considered to be an all-or-none phenomenon, in either clinical evaluation or measurement, but rather a dimensional one, so that subjects can have different levels of awareness of their illness (Surguladze and David, 1999).
All mental illnesses will alter the patient’s world view and capacity to cope with circumstances.
Assessment of insight measures the awareness of this change by the patient and his ability to adapt to the change. Insight is highly complex as a function. It is the understanding of the individual about his own state of health, capacity and worth; it also relates this assessment of internal state to other people and the world outside. In other words, insight requires both inner and outer orientation. This aspect of insight becomes more apparent, below, in the discussion about the contribution of gestalt psychology to the conceptualization of insight. Insight in gestalt psychology is oriented towards problem solving in the external world, whereas insight in clinical practice is inner-directed.
David (1990) regards insight as composed of three distinct, overlapping dimensions, namely, the recognition of morbid psychological change, the labelling of this change as deriving from mental illness and the understanding that this change requires treatment that needs to be complied with. An assessment schedule was constructed for determining the nature of insight, and quantitative loss of insight correlated with the degree of psychopathology (David et al., 1992).
One of the most frustrating aspects of practising psychiatry is, from the point of view of the treating professional, the apparent inability of patients to recognize and/or admit that they are mentally ill. Patients, especially those with schizophrenia, often deny that their experiences are abnormal and that they are unwell. Daniel Schreber (1842–1911) described his attitude towards his auditory verbal hallucinations in his book Memoirs of My Nervous Illness (Schreber, 1955) as follows:
I noticed therefore with interest that according to Kraepelin’s TEXTBOOK OF PSYCHIATRY (5th edition, Leipzig, 1896, p. 110 ff ) which had been lent to me, the phenomenon of being in some supernatural communication with voices had frequently been observed before in human beings whose nerves were in a state of morbid excitation. I do not dispute that in many of these cases one may be dealing with mere hallucinations, as which they are treated in the mentioned textbook. In my opinion science would go very wrong to designate as ‘hallucinations’ all such phenomena that lack objective reality, and to throw them into the lumber room of things that do not exist.
Furthermore Schreber continues:
Science seems to deny any reality background for hallucinations … In my opinion this is definitely erroneous, at least if so generalized.
These quotations from Daniel Schreber demonstrate one of the most complex aspects of the nature of insight. This is the capacity to have an attitude towards abnormal experiences in others where one can recognize them as pathological, but to deny the abnormality of the experience in oneself, and to designate it as not being evidence of mental illness. This is so-called double book-keeping.
The resulting refusal to cooperate with treatment and rehabilitation causes long-term suf- fering for the patients and their carers. It is this capacity of patients to understand their own illness that is evaluated clinically in insight. Like many other concepts, terminological confusion exists, with textbooks describing insight as the patient’s capacity to form judgements about their own illness and mental state. In recent years, there has been a resurgence of interest in the concept, with attempts to define it reliably and quantifiably and to study its correlates (Kumar and Sims, 1998).
Overview of the Concept
The attitude of the patient towards his illness has obvious clinical implications, and insight tries to assess the awareness of the patient concerning the impact his illness has had on his life and his capacity to adapt to the changes brought about by it. As a function, it is highly complex and has to do with an individual’s evaluation of his self and non-self and their relatedness (see Chapter 12). In clinical practice, only certain aspects are given importance, such as the patient’s awareness of illness and compliance with prescribed treatment. The assessment of insight assumes more importance in psychosis, as the incongruence between the patient’s and others’ view of his illness often leads to difficulties with treatment. The convention in psychiatry is that insight is unim- paired in non-psychotic conditions, but it can be seen that a broader view nearer to the lexical definition is relevant when neurotic symptoms hamper the full realization of a person’s potential.
DEVELOPMENT OF THE CONCEPT
Contributions to the development of the concept of insight derive from psychopathology, gestalt psychology and psychoanalysis. In gestalt psychology, insight is conceived as a sudden, unexpected solution to a problem. According to Markova (2005), the ‘suddenness’ specifies an abrupt solution to a problem, the ‘unexpectedness’ refers to the surprise element of the event and the term ‘solu- tion to a problem’ signals the discreteness of the event in time. In essence, in gestalt psychology, insight is by definition related to a specific task, a problem that stands in need of solution in the external world. Furthermore, there has been extensive debate within gestalt psychology about the nature of insight, whether it is a unique human facility that is also a specific cognitive skill. The fact that, in gestalt psychology, insight refers to a problem in the external world distinguishes it from the concept of insight in clinical practice. In clinical practice, insight focuses on understand- ing of changes or happenings within an individual.
For Jaspers (1959), typically the patient’s attitude to his illness involves ‘an awareness of illness’
in which the patient ‘expresses a feeling of being ill and changed, but there is no extension of this awareness to all his symptoms nor to the illness as a whole. It does not involve any objectively correct estimate of the severity of the illness nor any objectively correct judgement of its particular type’. For Jaspers, ‘only when all this is present and there has been a correct judgement of all the symptoms and the illness as a whole according to type and severity, can we speak of insight [emphasis in original]’. Thus, for Jaspers insight becomes manifest only when the patient is able to turn away from the content of his psychic experiences towards making a judgement about it and inquiring into its causes and reasons. Lewis’ (1934, p. 333) definition of insight as ‘a correct attitude to morbid change in oneself ’, is a restatement of Jaspers’ description of insight. Freud (1981) used the term insight to denote knowledge of illness but, on the whole, in psy choanalytic therapy the development of a deeper awareness of self is considered to be the goal of treatment.
This is another way of saying that in psychoanalysis, insight refers to knowledge and understand- ing of one’s unconscious mental processes. This is a more complex notion of insight, because it involves the patient acquiring understanding of the unconscious motivations of his behaviour and, in the light of Freud’s structure of the mind, it suggests a degree of depth of understanding.
David (1990) has proposed that insight is composed of the three overlapping dimensions described above. It has been suggested that parallels can be drawn between the loss of insight in psychiatric patients and the loss of awareness of disease of parts of the body in certain neurological conditions. In cortical blindness, left-sided hemiplegia following stroke and amnesic syndrome, lack of awareness of disease is well recognized. The term anosognosia was coined by Babinski (1857–1932) to refer to the unawareness or denial of hemiplegia seen in patients following a stroke. There is a difference, though, between the lack of insight seen in psychiatry and the lack of awareness seen in neurological disease. In psychiatry, lack of insight is often attended by a
wider loss of judgement beyond merely the symptoms or their implications for the patient. In neurological cases, the lack of awareness is focused on a discrete disability. Nonetheless, even though the lack of insight in psychiatry and lack of awareness of disease in neurology are not identical, it may be that comparisons may point to possible neurobiological bases that they share in common.
There are certain philosophical problems when we consider insight in patients with psychosis.
People without any psychiatric illness vary in their ability to know themselves and the conse- quences of their personalities. Because at least some conceptualizations of psychosis rely on the lack of insight as a defining feature, discussion concerning the concept can become circular. Added to this is the fact that varying degrees of insight can occur and that non-verbalization of insight may be different from the lack of it. Yet another problem is that a possibly specious model in which a ‘normal’ part of the mind is capable of passing judgement on the ‘abnormality’ of another part has to be entertained. This works for as long as the clinician recognizes that it is merely a way of speaking, not necessarily an accurate representation of how self-monitoring takes place.
MEASUREMENT OF INSIGHT
Earlier attempts to measure insight centred on its role in psychodynamic therapies. Tolor and Reznikoff (1960) developed a test using hypothetical situations based on common defence mechanisms and found a correlation with intelligence. This test was used by Roback and Abramowitz (1979), who found a correlation in those with schizophrenia between greater subjec- tive distress and better behavioural adjustment. The validity of this test for general clinical work is affected by the concept of insight being based on psychodynamic rather than psychopathologi- cal features.
Any reliable and valid measure of insight in clinical practice should be based on the following four assumptions:
■ insight is complex and multidimensional
■ cultural factors need to be taken into account
■ the level of insight can vary across the many manifestations of mental illnesses
■ information about the nature of a person’s illness from situations other than the interview should be taken into account (McGorry and McConville, 1999).
McEvoy et al. (1989a) developed a questionnaire to measure insight, defined as the patient’s awareness of the pathological nature of his experiences and also his agreement with the treating professionals about the need for treatment. The Insight and Treatment Attitudes Questionnaire (ITAQ) is a validated 11 item, semi-structured interview that generates a score from 0 (no insight) to 22 (maximum insight). Using this questionnaire, they found no correlation with aspects of acute psychopathology.
The Schedule for Assessment of Insight in Psychosis was published in 1992 (David et al.
1992), in which, apart from the recognition of mental illness and compliance with treatment, the ability to relabel unusual mental events as pathological was also included. There were seven items with a maximum possible score of 14 and an additional item on hypothetical contradiction.
The Scale to Assess Unawareness of Mental Disorder (Amador and Strauss, 1993) is a much more comprehensive scale with six general items and four subscales, from which ten summary scores can be calculated. Other scales available are the Global Insight Scale (Greenfield et al., 1989) and the self-reported Insight Scale for Psychosis (Birchwood et al., 1994). The scale by Markova and Berrios (1991) is more directed to evaluating aspects of self-awareness and less to clinical definition of insight with regard to illness. This is also true for the Beck Cognitive Insight Scale (Beck et al., 2004) which measures a wider notion of insight, encompassing patients’
capacity for evaluating their anomalous experiences and their erroneous inferences. The scale is composed of two subscales: self-reflectiveness and self-certainty.