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Ronald W. Pies's avatar

Thanks for the excellent "anatomy of insight" essay, Awais! In practical, clinical terms, I think you captured the crux of the matter in writing,

"Profound impairments in decision-making are a reality, and it serves no one to pretend that they don’t exist."

Furthermore, if we dispense with the concept of "impaired insight", we leave ourselves unable to attribute "good insight" to our patients--which, fortunately, many patients possess and for which they deserve much credit. In short, we need both sides of the conceptual coin.

With regard to impaired decisional capacity and involuntary treatment, I am reminded of the maxim attributed to Hippocrates: "If sick men fared just as well eating and drinking and living exactly as healthy men do…there would be little need for the science [of medicine]." [1]

Equally, if people with severe mental illness fared just as well as those without mental illness, there would be little need for the concept of "impaired decisional capacity." Alas, as we know all too well, this is not the case.

Ronald W. Pies, MD

1. https://www.psychiatrictimes.com/view/trivializing-suffering-psychosis

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Joseph Meyer's avatar

You write, "Delusions are not the result of a patient exercising their autonomy to develop their own narratives. It is foolish to think that they are. To think so is to profoundly misunderstand the nature of delusions." Can you explain why? Another psychiatry blogger wrote that persons with delusions make the error of building a belief system that confirms and reinforces misperceptions of the world around them. (I don't know if that would be a cause or effect of delusions.) I am a novice parent/caregiver and have sometimes wondered if my family member with autism and schizophrenia develops her own narrative and believes it partly because of a strong and grandiose desire for control that was evident in her temperament from infancy and which she is able to attain only in fiction.

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