Insight

Disturbed insight has been at the core of many conceptions about the nature of psychopathology and insanity. The mentally ill is described as “out of touch with reality” when they fail to appreciate the bizarreness of the symptom or even to acknowledge its existence. There is a difference in level of insight between Neurosis and Psychosis. In neurosis, for example Obsessive Compulsive Disorder, patients experience recurring bizarre thoughts which appear alien to them and unwanted. However, they confirm that these strange thoughts are symptoms of abnormal condition or accept such explanation without hesitation. This is in contrast to the assertion of a patient with schizophrenia who affirms the authenticity of such impossible ideas as his own thoughts being broadcast by radio waves to other people’s heads who can know everything he thinks of. The schizophrenic symptoms are ego-syntonic (in harmony with or acceptable to the needs and goals of the ego) while the obsessive-compulsive symptoms were ego-dystonic (alien, unwanted, and inconsistent with self-image).

In the realm of psychological therapies, in particular dynamic analytical psychotherapies, lack of insight is a causative factor in generating psychological illness and such therapies aim to restore such insight as curative measure. Such view considers that uncovering the unconscious conflicts is restorative and the lack of awareness of drives and wishes has generated symptoms. In a broader sense, both Truth (accurate knowledge about self) and Health (psychological well-being) are highly positively correlated. All psychotherapies help patients to think accurately about themselves and their involvement with the external world.

The term insight is used differently in ordinary language than in psychopathology. In ordinary usage, insight describes the capacity to apprehend intuitively the inner nature of things. In psychopathology, insight indicates impairment of information about the “self”. Psychodynamic formulation presumes that unawareness of symptoms is motivated by the special affective significance of information about the self. However, impaired insight is not just unawareness of symptoms, but also making inappropriate attributions for the source of these symptoms. The patient may acknowledge his psychotic symptoms which he consider as a result of poison put in his drink by his assumed enemies.

Lack of insight can occur when either the patient’s beliefs are implausible or he/she fails to appreciate such implausibility. In information-processing terms, there is dysregulation in error checking due to deficits in the psychological processes involved in testing and comparing the content of perceptual experience or beliefs in the light of available evidence or consensual knowledge.

The phenomenon of anosognosia shares features with the gross denial of symptoms commonly seen in functional psychosis. Following right-hemisphere lesions, the brain-damaged patients deny that they are paralyzed on the left side of the body.

Theories which have tried to explain impaired insight can be organized as follows:

1. Impaired perceptual input: This leads to faulty inferential output although the Inferential processes are intact. For example a hearing loss can result in paranoid ideation— that is, the belief that people are whispering behind your back. Similarly, dysregulation of auditory or visual pathways can result in abnormal perceptual experiences (hallucinations). Since virtually all waking perceptual experiences are validated as real, a long personal history of validated perception would dictate accepting hallucinations as real.

2. Impaired inferential processes. This leads to absurd ideas, misattributions, and failure to recognize implications. This explains failure of patients with delusions to alter beliefs in the face of antagonising evidence or to appreciate the importance of such evidence.

3. Impairment in the process of self-monitoring. The distinction between internally and externally generated phenomena may be impaired. For example, the patient with auditory hallucinations may be engaged in subvocal speech, but be unaware that the speech is self-generated.

4. Impairment in the processes of error checking. The "capacity to doubt" is impaired owing to deficits in matching the product of information processing against consensual information as to what is definite, likely, possible, and improbable.

5. Impaired thought-affect association. In this view, affective responses are inappropriate relative to the content of thought.

6. Impaired capacity to maintain a representation in memory over time (maintain a mental set), organize behavior sequentially, and sustain effort to establish and achieve a goal or plan. Deficits in these domains lead to a mismatch between intellectual appreciation of the implications of beliefs and subsequent behavior.

A variety of phenomena might be considered as features of impaired insight. These include failure to recognize signs, symptoms or the presence of disease, misattribution of the source or cause of these signs or symptoms, or failure to appreciate the implausibility of the perceptual or cognitive experiences.

Reference:

Xavier F. Amador, Anthony S. David: Insight and psychosis, Oxford University Press US, 1998 (ISBN 0195084977, 9780195084979)