Insight - Psychiatry

Insight is one of the crucial components of a mental status examination in Psychiatry. Scarce data is available in the standard textbooks on this concept.
The following presentation was made after going through the myriad of articles and case studies i found online.

1. INSIGHT Dr Ashish Debsikdar Resident- Psychiatry

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

3. -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 .

4. 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.

5. 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.

6. - 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)

7. - 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.

8. Multi-dimensional model of Insight By Amador and David 1998 Awareness that one is suffering, in a general way, from a mental( as opposed to a physical) disturbance which could be an illness. 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. Acknowledgement of the medical implications of the above, a concrete token of which is informed acceptance of treatment.

9. 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.

10. 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.

11. 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}.

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

13. 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!

14. 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.*

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

16. 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.

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

18. 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.

19. 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

20. 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.

21. -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.

22. 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. -

23. -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

24. 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.

25. 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.

26. -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. -

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

28. 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)

29. --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)

30. Some studies/articles and their salient points.

31. 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.

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

33. 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.

34. 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.

35. Insight was assessed using:- A semi structured interview, PANSS- item on Insight (G12) 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.

36. 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.

37. 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).

38. 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.

39. 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.

40. 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.

41. 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.

42. Standardized insight rating scales

43. -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.

44. -Sanz and colleagues 14 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.

45. 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, delusional interpretation of hospitalization, and lack of cooperation with treatment staff.

46. -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*

47. 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? ”

48. 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.

49. 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.

50. 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.

51. 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 you think you have a condition that . . . ?”)

52. The Scale to Assess Unawareness of Mental Disorder (SUMD) - Amador et al 1994 . it assesses:- Awareness of the mental disorder Consequences of the mental disorder Effects of medication Hallucinatory experiences Delusions Thought disorder Flat or Blunted Affect Anhedonia Asocialty

53. 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

54. 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.

55. 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 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.

56. 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.

57. MANAGEMENT

58. 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.

59. 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.

60. 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.

61. 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.

62. 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.

63. 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.

64. 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.

65. Erik Erikson

66. 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 far-reaching failure, which delays development.

67. -In the 2 nd chapter of his book- “Nature of Clinical Evidence”, he explains the role of a psychotherapist in helping the patients to gain identity. -In his 3 rd 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.

68. CASE VIGNETTES

69. 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.”

70. 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.

71. 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 embraced her real mother.

72. 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?

73. THANK YOU