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.
I very much appreciate your emphasis in the article linked to on the importance of grasping the profound suffering and dysfunction that is part of serious mental illness. And the way this agony of suffering can actually have a physical expression, as so vividly described by the patient who experienced every part of his body being torn up by people around him. My daughter, with a diagnosis of bipolar illness with psychosis, is housebound by what she experiences as debilitating physical pain. I don’t think she has the kind of paranoid delusions about the source of the pain as the patient mentioned, but she clearly experiences it, and it has become her jailor.
Thanks for the eloquent words from Hippocrates and your sensible application of them to impaired decisional capacity, which one might expect to be a symptom of illness affecting the brain. We do not seem to struggle with that concept in Alzheimer's or intellectual disability, perhaps because the symptoms of those disorders less often look like moral failings.
Thank you, Mr. Meyer--much appreciated! And your point re: Alzheimer's is well-taken. I suspect there is an insidious bias that accounts for the discrepancy you cite; i.e., "Well, Alzheimer's is a real brain disease, because we can see amyloid deposits in the brain; whereas schizophrenia and "psychosis" are just socially constructed labels...." etc. etc.
Another example, in my view, of the baneful intrusion of anti-psychiatric prejudice into the real world of medical illness. --Regards, Ron
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
I very much appreciate your emphasis in the article linked to on the importance of grasping the profound suffering and dysfunction that is part of serious mental illness. And the way this agony of suffering can actually have a physical expression, as so vividly described by the patient who experienced every part of his body being torn up by people around him. My daughter, with a diagnosis of bipolar illness with psychosis, is housebound by what she experiences as debilitating physical pain. I don’t think she has the kind of paranoid delusions about the source of the pain as the patient mentioned, but she clearly experiences it, and it has become her jailor.
Thanks for the eloquent words from Hippocrates and your sensible application of them to impaired decisional capacity, which one might expect to be a symptom of illness affecting the brain. We do not seem to struggle with that concept in Alzheimer's or intellectual disability, perhaps because the symptoms of those disorders less often look like moral failings.
Thank you, Mr. Meyer--much appreciated! And your point re: Alzheimer's is well-taken. I suspect there is an insidious bias that accounts for the discrepancy you cite; i.e., "Well, Alzheimer's is a real brain disease, because we can see amyloid deposits in the brain; whereas schizophrenia and "psychosis" are just socially constructed labels...." etc. etc.
Another example, in my view, of the baneful intrusion of anti-psychiatric prejudice into the real world of medical illness. --Regards, Ron