Insight in clinical psychiatry revisited

doi:10.1016/S0010-440X(95)90118-3

Comprehensive Psychiatry

Volume 36, Issue 5, September–October 1995, Pages 367-376

https://doi.org/10.1016/S0010-440X(95)90118-3 Get rights and content

Abstract

Current research on insight in psychiatry has focused on exploring the relationship between insight and other clinical variables such as severity of psychopathology, compliance with medication, general outcome, and, more recently, neuropsychological impairments. However, the studies yield divergent and inconsistent results, and consequently the role of insight in relation to such variables remains unclear. We review here recent studies in this area and suggest that one reason for variability in the results relates to confusion surrounding the term “insight.” It is argued here that more conceptual work is needed to help clarify the meaning of insight before further empirical research is undertaken. Some of the conceptual issues are raised, and it is suggested that the concept of insight is first differentiated from the phenomenon of insight (its clinical representation) to facilitate a more structured and systematic approach to the examination of insight in clinical practice.

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Cited by (79)

Clinical insight level predicts successful quit or control attempts during the first three months of outpatient addiction treatment
2022, Drug and Alcohol Dependence
Citation Excerpt :
Insight is a multidimensional mental state defined as “the capability of psychiatric patients to recognize and accept that they are suffering from a mental illness” (Thirioux et al., 2020). Clinical insight, one sub-dimension of insight, is the capability to recognize one’s mental illness, its symptoms and consequences, and to consent to related medical care (Amador et al., 1991; David, 1990; Jaafari and Marková, 2011; Marková and Berrios, 1995; Thirioux et al., 2020). Individuals with low insight into addiction are known to overestimate their capacity to quit by themselves or control their use (Rinn et al., 2002).
Low clinical insight in psychiatry is defined as poor recognition of one’s mental illness, including disability to self-evaluate symptom severity. It has been reported as common in addiction and is associated with lower treatment compliance. Longitudinal studies suggest that low clinical insight could be linked to more relapse. However, association with successful quit attempts remains unknown.
Our objective was to examine the prospective link between baseline clinical insight level and self-reports of successful attempts to quit / control use during the first 3 months of outpatient addiction treatment.
Participants were recruited from the ADDICTAQUI cohort at outpatient treatment intake for substance or behavioral addictions. They completed a baseline evaluation using the Addiction Severity Index (ASI), the Mini International Neuropsychiatric Interview (MINI), and the modified Hanil Alcohol Insight Scale (m-HAIS) with a follow-up ASI 3 months later. Data were analyzed using multiple logistic regression and non-parametric tests.
Lower clinical insight level at baseline was associated with less successful quit / control attempts during the first 3 months of outpatient treatment compared to a higher clinical insight level, controlling for sociodemographic factors, baseline addiction severity, and comorbidities (n = 54; exp(B) = 0.76; p (FDRcor) = 0.033).
Poor clinical insight may be a barrier to treatment success, and future studies should examine underlying mechanisms.
The insight paradox in schizophrenia: A meta-analysis of the relationship between clinical insight and quality of life
2020, Schizophrenia Research
Citation Excerpt :
To have intact insight, one must be able to form a coherent account of psychiatric challenges and how to manage them (Vohs et al., 2016). Clinical insight is considered a multidimensional construct with distinct, but interrelated subdomains (Lincoln et al., 2007; Markova and Berrios, 1995). Four key factors are typically cited in these conceptualizations: 1) awareness of illness; 2) consequences of illness; 3) need for treatment; and 4) illness attribution.
Poor clinical insight affects people with schizophrenia and has been cited as a chief cause of poor outcomes. As such, clinical insight is often a target of intervention; however, increases in insight have shown associations with decreased quality of life in a phenomenon known as the “insight paradox.” Understanding the relationship between insight and quality of life is important as clients often feel hopeless when quality of life decreases. This meta-analysis sought to clarify relationships between clinical insight, its subdomains, and quality of life in schizophrenia. Further, we explored the role of two moderators (quality of life measurement type, symptom severity) on the insight-quality of life relationship. Studies were identified according to PRISMA guidelines through a focused literature search extending to March 1, 2019. Correlations between clinical insight, its subdomains, and quality of life were extracted and used to calculate overall mean weighted effect sizes using a random-effects model. In support of the insight paradox, overall clinical insight was inversely related to quality of life. Symptom severity moderated the relationship between clinical insight and quality of life, such that greater symptom severity weakened the inverse relationship between overall insight and quality of life. Regarding subdomains of clinical insight, awareness of illness was inversely associated with quality of life; however, other subdomains failed to reach significance. Our findings support the notion that increased insight is associated with lower quality of life and highlight the need for further exploration of the role of meaning-making processes on this relationship.
Insight and suicidality in psychosis: A cross-sectional study
2017, Psychiatry Research
Citation Excerpt :
The sample was dichotomized into “poor insight” (all scores over 1) and “good insight” (scores of 1) for each insight dimension. In order to evaluate subjective insight considering patients’ views, the Markova and Berrios Insight Scale (MBIS) (Markova and Berrios, 1992, 1995) Spanish version (Nieto et al., 2012) was also administered. This scale consists of 30 statements which are labelled by patients as true or false.
We aimed to test whether specific insight dimensions are associated with suicidality in patients with psychotic disorders.
143 patients with schizophrenia spectrum disorders were recruited. Suicidality was assessed by item 8 of the Calgary Depression Scale for Schizophrenia (CDSS). Insight was measured by the Scale of Unawareness of Mental Disorder (SUMD) and the Markova and Berrios Insight Scale. Bivariate analyses and multivariable logistic regression models were conducted.
Those subjects aware of having a mental illness and its social consequences had higher scores on suicidality than those with poor insight. Awareness of the need for treatment was not linked with suicidality. The Markova and Berrios Insight scale total score and two specific domains (awareness of “disturbed thinking and loss of control over the situation” and “having a vague feeling that something is wrong”) were related to suicidality. However, no insight dimensions survived the multivariable regression model, which found depression and previous suicidal behaviour to predict suicidality.
Suicidality in psychosis was linked with some insight dimensions: awareness of mental illness and awareness of social consequences, but not compliance. Depression and previous suicidal behaviour mediated the associations with insight; thus, predicting suicidality.
Correlation Between Insight and Capacity to Consent to Research in Subjects With Bipolar Disorder Type I and Schizophrenia
2016, Revista Colombiana de Psiquiatria
Citation Excerpt :
These findings are consistent with similar studies carried out on these types of patients, not only for research but in the clinical area, with regards to accepting or refusing treatment for their disease.23,29 Various authors have already highlighted the importance of insight in severe mental disorders,30–33 not only as a factor to take into account when establishing the prognosis and evolution of the diseases,34 but also as a determining factor in understanding and establishing how the subject perceives their own disorder.35 The results also confirm the existence of differences in their capacity for informed consent for participating in research among the patients with severe psychiatric disorders and the healthy control subjects, as well as differences in the degree of compromise among the patients schizophrenia and BD-I. Finally, the findings show that the level of impairment of the patient's insight interferes with their capacity for informed consent and that both functions —insight and capacity to consent— might be interrelated superior mental processes, affected to different extents by the severity of the disorder.
Schizophrenia and bipolar disorder type I (BD-I) can affect patient autonomy and capacity to consent to participate in research. Other variables associated with the autonomy of patients must be explored in order to improve the quality of the currently available tools.
To evaluate the relationship between insight and the capacity to consent to participate in research in patients with BD-I and schizophrenia.
A cross-sectional and longitudinal study was conducted with 120 subjects (40 subjects with schizophrenia, 40 with BD-I, and 40 healthy controls). The tools used were the Scale Assessment Insight-Expanded (SAI-E) and the MacArthur Competence Assessment Tool-Treatment (MacCAT-CR), which was first adapted culturally, and its validity and reliability assessed. The results obtained on each scale were compared and the association between them were evaluated.
There is a direct correlation between the capacity to consent to research, measured using the MacCAT-CR tool, and the degree of insight, measured using the SAI-E scale, with an effect size of 1.3 for BD-I and 2.03 for schizophrenia.
The results suggest that there is a correlation between the degree of insight and the capacity to consent to research in subjects with schizophrenia and BD-I. Insight should therefore be included as a relevant variable to assess the capacity to consent, and future studies should include it when researching on or designing new tools which aim at a greater respect of patient autonomy.
La esquizofrenia y el trastorno afectivo bipolar tipo I (TBI) pueden afectar a la autonomía del paciente y su capacidad para consentir a la participación en proyectos de investigación. Otras variables asociadas con la autonomía de los pacientes deben ser exploradas con el fin de mejorar la calidad de los instrumentos actualmente disponibles.
Evaluar la relación entre la introspección y la capacidad de consentir a la participación en investigaciones en pacientes con TBI y esquizofrenia.
Estudio longitudinal de corte transversal, en el que se incluyó a 120 sujetos (40 con esquizofrenia, 40 con TBI y 40 controles sanos). Las herramientas usadas fueron The Scale Assessment Insight-Expanded (SAI-E) y The MacArthur Competence Assessment Tool-Treatment (MacCAT-CR), que se adaptaron culturalmente antes de evaluar su validez y su confiabilidad. Se compararon los resultados obtenidos de cada escala y se evaluó la asociación entre estas.
Hay correlación directa entre la capacidad de consentir a la participación en investigaciones, medida por la herramienta MacCART-CR, y el grado de introspección, medido por la escala SAI-E, con un tamaño de efecto de 1,3 para TBI y 2,03 para esquizofrenia.
Los resultados indican que hay correlación entre el grado de introspección y la capacidad de consentir de los sujetos con esquizofrenia y los pacientes con TBI. Por lo tanto, la introspección debería incluirse como una variable relevante para evaluar la capacidad de dar consentimiento a la hora de participar en un estudio de investigación. Además, los estudios futuros deberían incluirlo para la investigación o diseño de nuevas herramientas que apunten a un mayor respeto de la autonomía de los pacientes.
Effects of antipsychotic drugs on insight in schizophrenia
2014, Psychiatry Research
Citation Excerpt :
Among these scales, the most used nowadays are the Schedule for the Assessment of Insight developed by David et al. (1992) and the Scale to Assess Unawareness of Mental Disorder developed by Amador and Strauss (1990). In the last years insight has been investigated in relationship with the severity of psychopathology (Hayashi et al., 1999), the acceptance of therapy (Misdrahi et al., 2012) and the cognitive impairment (Markova and Berrios, 1995). Despite some studies investigated these issues, no definitive conclusion has been drawn so far.
Lack of insight is predominant in schizophrenia though the causes are still unclear. The present study was carried on to investigate the effect of three Second Generation Antipsychotics (SGAs) and Haloperidol on insight and the associations among different clusters of symptoms and insight. Fifty-five patients have been recruited at the moment of pharmacological switch needed for psychotic exacerbation, from other antipsychotic drugs to Olanzapine, Aripiprazole, Ziprasidone and Haloperidol. Patients have been followed for 6 months and evaluated at baseline, after 3 months and after 6 months. Regarding the insight improvement, all SGAs resulted more effective than Haloperidol, while no difference was detected among different SGAs. Concerning psychopathology, all SGAs showed a better efficacy than Haloperidol, positive symptoms apart. All SGAs showed a similar efficacy on all domains, except for negative symptoms which resulted less responsive to ziprasidone and haloperidol. An association between improvement of insight and psychopathology was detected. Furthermore, insight appears to be related to psychopathology severity, particularly to negative symptoms. However, the observed different effectiveness of Ziprasidone on negative symptoms and insight suggests that these psychopathological features may be not strictly related and, thus, they may be sustained by different psychopathological processes.
Insight in schizophrenia and risk of suicide: A systematic update
2012, Comprehensive Psychiatry
Suicide has been shown to represent the major single cause of premature death among patients with schizophrenia spectrum disorders. Insight has been proposed to increase such risk. However, this subject has not been sufficiently investigated, and inconclusive results have been reported.
The objective of this study is to systematically examine the role of insight in the risk of suicide attempts and completed suicide among patients with schizophrenia and related disorders.
Articles assessing insight and suicidality in patients with schizophrenia spectrum disorders published between 1977 and 2010 were reviewed. A MEDLINE search strategy was used to identify studies using keywords. Application of meta-analytic techniques to selected studies was not possible because of important methodological differences between them.
Fifteen studies met predetermined selection criteria. Ten failed to demonstrate a positive association between insight and risk for suicide.
There is little evidence to support the suggestion that insight may represent a risk factor for suicide in patients with schizophrenia. If there is an association between such risk and insight, it appears to be mediated by other variables such as depression and, above all, hopelessness. Further studies with larger samples and longer follow-up periods in naturalistic conditions, in which insight should be evaluated from a multidimensional approach, are required to analyze this issue in depth, given the crucial implications that it may have on the development of a model for suicide prevention in schizophrenia.

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Insight in clinical psychiatry revisited

Abstract

Schizophr Res

Biol Psychiatry

Insight and the clinical outcome of schizophrenic patients

J Nerv Ment Dis

Assessment of insight in psychosis

Am J Psychiatry

Insight and adherence to medication in chronic schizophrenics

J Clin Psychiatry

Clinical symptomatology and drug compliance in schizophrenic patients

Acta Psychiatr Scand

Insight in schizophrenia. Its relationship to acute psychopathology

J Nerv Ment Dis

The assessment of insight in psychosis

Br J Psychiatry

Awareness of illness in schizophrenia and schizoaffective and mood disorders

Arch Gen Psychiatry

Insight in schizophrenia and mood disorders and its relation to psychopathology

Acta Psychiatr Scand

Psicopatologia y conciencia de enfermedad durante la fase aguda de la esquizofrenia

Rev Psiquiatr Fac Med Barcelona

Insight about psychosis among outpatients with schizophrenia

Hosp Community Psychiatry

Lack of insight in schizophrenia

Schizophr Bull

Insight and its related factors in chronic schizophrenic patients: a preliminary study

Eur J Psychiatry

A self-report insight scale for psychosis: reliability, validity and sensitivity to change

Acta Psychiatr Scand

Insight and prognosis

J Clin Psychol

Drug refusal in schizophrenia and the wish to be crazy

Arch Gen Psychiatry

Early insight and the management of schizophrenic decompensation

J Nerv Ment Dis