Judgement

Brief about judgement & Insight

1. Judgment and Insight Dr wasim UNDER GUIDANCE OF DR Gunjan solanki

2. The concept of insight is much larger than just knowing whether one is ill or not, and if so, having a sensible view regarding treatment. It involves our capacities for introspection, empathy and communication. It also includes knowing how our behaviour will affect the emotions and experience of other people as they go through the same mental mechanisms. INSIGHT

3. insight requires both inner and outer orientation. It is a quality that has been highly valued by mental health clinicians because a strong link between having insight and better quality of life.

4. We ask specific questions about the patient's opinions concerning his illness. These include his degree of acknowledgement 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.

5. Thus insight is not an all-or-none phenomenon, in either clinical evaluation or measurement. Rather a dimensional one, so that subjects can have different levels of awareness into their illness.

6. In gestalt psychology, insight is conceived as a sudden, unexpected solution to a problem. the ‘suddenness’ specifies an abrupt solution to a problem, the ‘unexpectedness’ refers to the surprise element of the event and the term ‘solution to a problem’ signals the discreteness of the event in time. Development of the concept

7. In gestalt psychology insight refers to a problem in the external world. however in clinical practice, insight focuses on understanding of changes or happenings within an individual.

8. David (1990) has considered that insight is 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.

9. Amador and David expanded the concept of insight with five different dimensions for insight in Schizophrenia: Awareness of having a mental illness. Awareness of symptoms of mental disorder. Attribution of symptoms to a mental disorder. Awareness of the consequences of mental illness Awareness of the effects of medication.

10. Both have: A severe lack of awareness of their deficits. A strong desire to prove their own assertions. Invent confabulations to explain away pathological symptoms. Often demonstrable Frontal lobe deficits. In psychiatry, lack of insight is often attended by a wider loss of judgement beyond merely the symptoms or their implications for the patient. Lack of insight in Psychiatry and anosognosia in neurological disorders ( cortical blindness, left-sided hemiplegia )

11. 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

12. -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 have all noted a positive correlation between increasing insight and increasing depression.* * (Smith et al. 2004,Weiler et al. 2000, Carroll et al. 1999) The Psychological Defense Model:-

13. -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.

14. 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.

15. -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. -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.

16. -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. Neuropsychological Deficit Model:-

17. 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. Factors influencing insight

18. Unawareness and misattribution of symptoms in schizophrenia may have distinct neuroanatomical bases. DLPFC deficits may result in illness unawareness by interfering with self-monitoring. OFC abnormalities may mediate symptom misattribution by conferring aberrant salience to perceived symptomatology.* schizophrenia with preserved insight is associated with greater perfusion of the precuneus , a brain area known to be involved in self- consciousness.** *Prefrontal subregions and dimensions of insight in first-episode schizophrenia — A pilot study, mujjeb U Shad et al 2005 **Catherine Faget-Agius et al, Schizophrenia with preserved insight is associatedwith increased perfusion of the precuneus . Neurobiological evidence

19. There is a “Cortical Midline System” (CMS) — The medial frontal cortex ( ventromedial , Brodmann areas [BA] 10, 11, and dorsomedial BA 9) cingulate cortex These are engaged in tasks encompassing self-reflection, most often engaged when “self-appraisal” was contrasted to “other-appraisal.” “FAILURE TO DIFFERENTIATE SUFFICIENTLY BETWEEN SELF AND OTHERS…” Other regions

20. Complete denial of illness Slight awareness of being sick and needing help, but denying it at the same time Awareness of being sick but blaming it on others, on external factors, or on organic factors Awareness that illness is caused by something unknown in the patient Intellectual insight : admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences True emotional insight : emotional awareness of the motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behavior . Grading of insight

21. Mania Psychosis Drug and alcohol dependence Depression Personality disorders Dementia Delirium Attention deficit disorder Obsessive-compulsive disorder Central nervous system disorders Conversion disorder Examples of disorders whose symptoms may contribute to impaired insight and judgment

22. Actively psychotic patients with paranoid schizophrenia often do not appreciate that they are mentally ill or how treatment can be helpful. Psychosis from any cause involves psychotic and immature defense mechanisms that are not compatible with being insightful. for example, projecting onto another person one's own feelings (believing that the doctor has sexual feelings for the patient, when the converse is true). Persons who use psychotic, immature, and neurotic defense mechanisms are less capable of achieving full insight than are those who utilize mature mechanisms.

23. Manic patients are usually so immersed in their elated or hyperactive state, they may be having so much fun that they do not realize they are behaving abnormally relative to their usual selves or to society. Manics and narcissistic personality-disordered persons tend to be grandiose about their capabilities, thereby diminishing their ability to be realistically aware of their condition or their limitations.

24. Extreme lack of insight is associated with conversion disorder (a dissociative state), factitious disorder, addictive disorders, and psychoses. By its very nature, conversion disorder implies a lack of conscious awareness of the underlying psychological conflict that is masked and or symbolized by the presenting somatic symptom. Alcoholics and drug abusers frequently deny their addictions and the consequences thereof, externalize blame, do not take responsibility for themselves,

25. Many personality -disordered persons have inadequate insight into their disturbed relationships, thinking, and feelings, and are often resistant to changing these patterns. Borderline personality-disordered patients often use black and white thinking in which people or events are viewed as extremely good or bad, without awareness of gray zones of relativeness . Severely depressed , suicidal patients have negatively distorted views of the world and themselves, which diminishes their ability to appreciate the positive aspects of living.

26. Demented, delirious , amnestic , and brain-injured patients (e.g., stroke, head trauma) are all cognitively impaired; because of their attentional , memory, language, or abstraction deficits, these patients are often not capable of being insightful.

27. 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. Measurement of insight

28. Scale to Assess Unawareness of Mental Disorders (SUMD) Insight and Treatment Attitude Questionnaire(ITAQ) Insight Scale (IS). Lack of Insight Index. Schedule for Assessment of Insight-Expanded (SAI) Beck Cognitive IS (BCIS) Present State Examination. Positive and Negative Syndrome Scale, item G12. Various scales available for assessment of insight include:

29. Item G12 (lack of judgment and insight), is used separately as an insight scale. 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. 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. Item G12. Part of the General Psychopathology section of PANSS.

30. 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. Schedule for the Assessment of Insight (SAI)

31. -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. The Insight and Treatment Attitudes Questionnaire (ITAQ)

32. Most of the research work on the clinical correlates of insight has been on patients with schizophrenia. Overall, it does appear that the relationship between poor insight and aspects of psychopathology is linear but complicated by other factors, including compliance with treatment. It has often been speculated that poor insight may have a neurological basis. Schizophrenia

33. subjects with impaired insight performed more poorly than subjects with unimpaired insight on the Wisconsin Card Sorting Test (WCST). However further studies have not reproduced these results. In another study, Upthegrove et al. (2002) showed that impaired digit span as a measure of working memory was significantly associated with insight. However, on balance, the issue of whether cognitive deficits underlie poor insight is still unresolved. Cognition

34. -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), ( 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) Bipolar disorder

35. On occassions patients may acknowledge “morbid change” merely “regurgitating overheard explanations,” which is a common occurrence in the inpatient settings, more so in patients with involuntary admissions. Pseudo Insight

36. The recent resurgence of interest in insight has had its share of criticism. Medical anthropologists have criticized the concept of insight for failing to recognize that people can have various culturally shaped frameworks to explain their illnesses, all possibly valid. From this point of view, the concept of insight is ‘ eurocentric and essentially arrogant. patients should, apart from agreeing that they are mentally ill and requiring treatment, also agree to reconstruct their experiences within the terms and concepts of western psychiatry. Criticism of concept

37. Johnson and Orrell (1995) have reviewed work by social scientists on cultural and social variations in lay perceptions of mental illness and argue that these would influence insight. Social and cultural backgrounds influence perceptions of stigma from mental illness and the congruence of the patients with western medical views of mental illness. For example, differences in the ethnic background of the psychiatrist and the patient appear to influence the judgement of the former about insight (Johnson and Orrell 1996).

38. Interventions

39. - 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. - clozapine may indirectly improve insight by improving negative symptom pathology, which in turn might make patients more amenable to psychosocial intervention programs. PHARMACOLOGY

40. good insight in schizophrenia patients is related to a strong social support network. -Interventions such as vocational rehabilitation , and a specifically modified form of motivational interviewing 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. NON PHARMACOLOGICAL

41. 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 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. I nsight oriented psychotherapy

42. Judgment is a process of consideration and formulation regarding a particular issue or situation that can lead to a decision or action. The better and more complete the person's insight, the more likely the judgment is to be sound. Because insight and judgment are related to each other, much of the above discussion on insight applies to judgment as well. Judgment involves weighing and comparing the relative values of different aspects of an issue. Judgement

43. The ability to make sound judgments requires adequate insightfulness, intact cognitive function, capacity to conceptualize, sensitivity to the impact and consequences of a decision, ability to consider long-term effects and possible adverse outcomes, and appreciation of what a person in society would do. Any impairment of these functions diminishes the quality of the resultant judgment.

44. Judgment is impaired in depressed patients when negative and pessimistic feelings distort reality; this may even culminate in suicidal acts. Suicide attempts are usually considered abnormal and evidence of poor judgment in our society, but are more acceptable in some other societies and less aberrant in our society when persons are in severe pain from terminal illness. Even if the process of judgment is sound, the outcome can be bad. Judgment may be impaired as a consequence of impaired insight from the neuropsychiatric effects of intoxication with drugs or alcohol, as evidenced by the many persons who confidently drive their cars while intoxicated. IMPAIRMENT OF JUDGEMENT IN PSYCHIATRIC DISORDERS

45. Manics are insensitive to others' feelings and have poor judgment regarding their social behaviors; they often insult or embarrass others by their jokes or actions. Manics who are euphoric have an unrealistically happy view of the world and do not recognize potential negative consequences of their behaviors. Therefore, they may go on spending sprees when they have insufficient funds to pay for the purchases; engage in socially improper behaviors such as parading nude in public.

46. Patients with attention deficit disorders cannot maintain their attention long enough to focus their thinking and may behave impulsively. In contrast, obsessive patients spend a great deal of time thinking, yet have difficulty formulating judgments because they get caught up in details or are rigidly bound by rules. Schizophrenics who are actively psychotic may not be fully capable of sophisticated decision making because of delusions, thought disorder, or unrealistic distortions due to referential thinking.

47. Certainly, a delirious or demented patient who has significant cognitive deficits cannot be expected to make a sound, informed decision. Patients who have prefrontal cortex damage have difficulty with higher-level conceptualization. Stroke patients may have damage to areas of the brain required for language, cognition, or executive functions and thereby be less capable of making sound judgments.

48. Disinhibition is the loss of self-restraint or internal monitoring of behavior, resulting in socially inappropriate behaviors, such as publicly masturbating or telling profane jokes in genteel company. A person's defense mechanisms can greatly affect his or her judgments; the more mature styles increase the likelihood of making rational judgments. Denial, projection, repression, externalization, and dissociation adversely affect judgment, whereas humor, altruism, and suppression are less likely to interfere.

49. The thinking or psychological performance required to produce a delusion is quite independent of intelligence. It occurs in clear consciousness with no signs of organic disturbance of the brain. Judgement in other areas of life apart from the delusion can be preserved, and the very ingeniousness the patient uses to explain and defend his delusional belief demonstrates that his essential capacity to think logically is largely intact. Disturbance of judgement and delusion

50. Social judgement is observed during the hospital stay and during the interview session. It includes an evaluation of ‘personal judgement’. Test judgement is assessed by asking the patient what he would do in certain test situations, such as ‘a house on fire’, or ‘a man lying on the road’, or ‘a sealed, stamped, addressed envelope lying on a street’. Judgement is rated as Good/Intact/Normal or Poor/ Impaired/Abnormal. Types

51. Thank you