Insight in psychosis: A critical review of the contemporary confusion

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Abstract

This commentary highlights the context, complexity, conflicting claims and the contemporary confusion related to insight in people with psychosis. Traditional psychiatric precepts suggests that good insight is inversely related to the severity of psychotic symptoms and directly related to depression scores, better clinical outcome, and treatment adherence. However, recent studies have recognised that insight does not predict outcomes, changes over time, and is dependent on the trajectory of the individual’s illness and the social and cultural context arguing that “insight” is an explanatory model and a coping strategy. Methodological issues related to the assessment of insight, the limitations of psychiatric classification and complex interaction between biology and the environment make simplistic explanations of the concept of insight less than useful. The paper argues that the biomedical model should be presented without dismissing or devaluing patient beliefs and explanations. Psychiatry needs to embrace the complexity of mental illness and value diverse attempts at restoring homeostasis.

Introduction

Insight involves intellectual understanding and emotional appreciation of issues related to illness (Sims, 2003; David, 1990). However, insight in people with psychosis is controversial. This commentary highlights the context, complexity, conflicting claims and the contemporary confusion.

Section snippets

Traditional concepts

Traditional psychiatric thought suggests that good insight is inversely related to the severity of psychotic symptoms (E.g. delusions, hallucinations) and directly related to depression scores, better clinical outcome, and treatment adherence (David, 2004; Mohamed et al., 2009). Many studies have attempted to identify underlying biological substrates (Shad and Keshavan, 2015; Van der Meer et al., 2013). However, diverse neural mechanisms have been implicated, albeit without consistency. In

Recent investigations

The majority of the investigations, which correlated clinical phenomena and biology with insight, employed cross-sectional study designs. In contrast, recent longitudinal studies have documented that insight scores at the onset of psychosis have limited predictive value and may not predict long-term outcomes (E.g. psychotic symptoms, disability and insight) (Johnson et al., 2012, 2014a; Johnson et al., 2014b). Investigations have also documented the impact of stigma (Cavelti et al., 2012) and

Methodological issues

These conflicting claims can be partially explained by methodological issues related to the assessment of insight and limitations of psychiatric classification. The concept of insight, which started as an all-or-none phenomenon evolved to single and multi-dimensional constructs (Sims, 2003; David, 1990; Murri and Amore, 2019). While recent dimensional conceptualizations improve our comprehension of the clinical phenomenon, they also add to its complexity. Interpretation is also complicated by

Complex interactions

On the other hand, longitudinal investigations and those which attempted to study potential confounders support a complex interaction between the person’s trajectory of illness and cultural milieu, between biology and the environment (Belvederi et al., 2016; Jacob, 2017). Recent studies on explanatory models of illness have documented the fact that people simultaneously hold multiple and contradictory models of causation and treatment (E.g. biomedical beliefs like disease, deficiency,

Implications for health care

The complexity of mental illness and the complicated nature of the clinical phenomenon of insight have major implications for health care. Clinical care mandates the recognition of the clinical syndrome, elicitation of patient perspectives, evaluation of the local context and culture, education of the patient and their families about possible interventions and negotiation of shared plan of management (Jacob, 2014). Consequently, mental health professionals should present the biomedical model

Authors contribution

KS Jacob trained in medicine, psychiatry, epidemiology and anthropology. He has studied insight and psychopathology and the impact of culture. He has worked in clinical and academic settings in India, the United Kingdom and in Australia. He recently retired as professor of psychiatry, Christian Medical College, Vellore, India. The author reviewed clinical practice, analysed literature, studied the impact of culture on insight in people with schizophrenia and wrote the paper.

Declaration of Competing Interest

None.

Funding

No specific funding received for this effort.

Acknowledgements

No funding was received for this effort.

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