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
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.
I meant a conscious, intentional process of developing a narrative. It is possible there may be something taking place at an unconscious neurological or psychological level that leads to psychosis. There are predictive processing theories of psychosis in which the brain processes of inference (that underlie perception and belief development) go awry or psychodynamic ideas of unconscious defense mechanisms. These are processes of a different sort than those involved in an individual exercising their autonomy.
My GP when she was sending me to my psychiatrist asked me "so how has your insight been" I replied that I didn't understand what she went, so she said "just say yes." Luckily she asked me to say yes
Political implications aside, I don't think it's likely that neurological and psychological anosognosia are really comparable entities that it makes sense to collapse. The anosognosia of, say, someone who is manic and doesn't realize they're talking a mile a minute, seems more akin to what happens when someone gets irrationally angry and doesn't realize their compliants are unfounded, than what happens when someone has a stroke and can't tell that they are paralyzed. I think psychological anosognosia is contiguous with 'ordinary' brain function, albeit much more extreme, than what happens consequent to neurological injury. But that's informed more by experience and scientific intuition than research. It's on the long list of things I've been meaning to investigate further and maybe write about.
That's a very comprehensive approach to anosognosia, Dinah, and I appreciate your well-balanced concern about involuntary commitment. But I'd put more emphasis on psychiatry's use of terms like anosognosia to bolster our medical bonafides. To me, this speaks to the field's insecurity about its own status. And yes, I too wrote a blog post about this, over a decade ago:
I sometimes think we are too sure of ourselves in terms of what is right or wrong (isn't everyone in our polarized world?) and should question ourselves more. Nice to see you in yet another online venue, Steve!
Interesting post. I'm not sure your narrow notion of insight captures how it's routinely used in mental status exams, for patients with all types of symptoms. I've never experienced psychotic or manic symptoms but have been written about as lacking insight. At my medical school, we've been taught to evaluate all patients with regards to insight and that insight includes understanding the need for treatment. Perhaps this is why I was thought to lack insight - I thought the treatment they proposed would make me feel worse. As it turned out, I experienced hospital treatment as terrifying, coercive and humiliating and I have nightmares about it years later.
I am sorry you had to experience this! As I mention in the post, attitudes towards treatment are related to/a part of insight, but there are also many legitimate reasons for patients to disagree with a proposed course of treatment, and it is inappropriate and wrong to use the mere fact of treatment refusal as a sufficient reason to describe someone as lacking insight.
Great stuff. I appreciate your nuanced approach. I think we’re basically in agreement in terms of how we think about insight in actual practice. For me the most important aspect is someone’s ability to say “I’m unwell and I need help”, and everything after that is secondary. But I’m still not convinced that rejecting the “knowledge of the cause of illness” part is totally justified. Is your argument based on our currently incomplete scientific knowledge of mental illness, and therefore someday when our understanding is demonstrably better we could incorporate knowledge of causes into "insight”? Or is insight in principle separated from knowledge of the causes of illness (and if so, does that apply to non-mental illness too)? The latter option seems to imply that “insight” is purely a function of subjective sense-making and not about understanding something true about the world. If that's the case, I'd need to rethink my concept of insight from the ground up. But maybe I'm missing something important here?
I think knowledge of the cause of the condition is relevant to insight but also distinct from it. Consider, for example, a patient who has recovered from delusions and now says, “I recognize now that I was delusional. It is so strange that I believed all those things. I have heard from my friends that delusions are caused by the schizophrenogenic mother, and certainly, my mother was a harsh, mean woman.” You gently try to explain that science has discredited that hypothesis, but he shrugs and says it fits his experience so he will continue to believe it. A different patient recovers from delusions and says, “My imam tells me that psychosis is a punishment from God for one’s sins. May Allah have mercy on my soul.” It would be odd IMO to say that both these patients, who fully accept that they were delusional, lack “insight” into the delusions. Wouldn’t this put insight at mercy of scientific fads and changing attitudes? Does a person have insight if they say mental illness is a “chemical imbalance” or a “mitochondrial disorder”? At the same time, I accept that incorrect ideas about causation can be so wrongheaded and can be held with such conviction that they can become grounds for lack of insight.
That is, insight cannot simply be about parroting whatever bullshit story about causation some clinician tells the patient. And insight cannot be about scientific knowledge (just as IQ properly understood should not be about prior knowledge). There has to be some room for patients to possess insight and disagree with the clinician on how to interpret their experience.
Certainly insight isn't related to spouting back faddish theories—an addict on his umpteenth round of rehab or someone going through DBT can tell us the theories really well, but may have no ability to translate that into useful therapeutic change. But what if we extend the analogy to other illness? Granted we don't talk about insight into diabetes in the same way as mental illness, but it seems to me that between two patients, both of whom have diabetes and have constructed equally functional and adaptive narratives to manage it, if one of them actually understands the physiology of diabetes and the other patient has some fictional account of why sugar is bad, the one with the accurate account must have at least a bit more insight. In practice, though, for most illnesses having a knowledge of the causes will directly translate into managing the illness better, hence my thought that once we understand mental illness as well as we do diabetes or heart failure, then understanding the causes would become more important. I suppose genetics is one current example since some people take their genetics into account when deciding about children (eg not wanting to pass on some inherited family illness). If you don't know that most mental illness has some genetic component, you're missing a big part of the picture.
On the other hand there's also the issue of clinical context which you also got into. Seems clear to me that it is much more important for a patient with, say, chronic interpersonal problems to understand the true causes of those problems, eg the patient's own behavior which could be modifiable, than for someone with schizophrenia to understand nitty gritty details about the brain which, even if correct, isn't likely to affect his illness.
You raise some great points. An accurate understanding of the causes, to the extent they are known, is advantageous to one’s orientation towards the condition. And perhaps it is desirable for the concept of insight to reflect that in some manner. Need to chew on this more!
It should be possible to discuss insight and lack thereof as a real thing, and simultaneously recognize that it's sometimes misused, and that there are some doctors who basically think "insight" means "agrees with me about everything".
Nice essay. It sort of started for me with Lewis’s statement sometime in the 1930s I vaguely recall but German Berrios and other learned and distinguished historians and practitioners established a much larger conceptual context and historical background. It fascinated me throughout my years in practice and your essay has caught some of the difficulties that I have had in pinning the concept down - it’s quite slippery, easily misunderstood, though very powerful in the intersubjective space between patient and therapist. Thank you.
I came on a refinement of self-knowledge which was a long time in the making. Since the related problems are so extreme, I believe mental health professionals couldn't identify a potential game changer. For one, the context in which they meet me, In a chair at an office, for that observational period, would make it impossible.
The key that picked the lock was when I noticed a level on which that addiction had infiltrated mundane tasks involving executive function. As I prepared food, I would go in and out of the room. Glancing at the computer screen for no reason. Then...
Just before or after I made a decision to buy some nicotine, my actions became more economical and more direct... purposeful looking activity.
The problem it may help: Since I was quite young, with almost no forewarning. I would have some level of frontal lobe over-activation.. It's very hard for me to cope with because i often involves memory and attentional impairment. I keep leaving treatment programs a couple of weeks in not really understanding why!
Now that I can spot this quirk of affect in the kitchen, I have physical and behavioral markers to give an ancillary cue to draw my attention.! That may seem insane, but I'll leave that to your clinical judgdement
I feel almost silly saying it. Among all the crazy behavior that would involve police, prisons and ambulances, a tiny change in how I cook when I thought of nicotine might be a lifesaver.
I found this a useful gathering of the ways "insight" is used. I share your view that the core meaning in the context of psychotherapy speaks to the level of the patient's capacity for introspection and self-awareness. In my practice, I've found that low-insight patients are not great candidates for more thoroughgoing psychoanalytic work (as Freud and others have emphasized). At least not initially. Because sometimes what appears as lack of insight, especially in more disturbed patients, turns out to be a defense...and once the defense is less needed, insight can start to develop. Thanks for your work.
Thanks very much, Ms. Wilbur. Yes: for me, the hallmark of serious illness/disease--in general medicine and psychiatry--is suffering and incapacity, as you well know. Thank you for sharing your experience. --Regards, Ron
We can think of the self as the first person model of one’s own agency, and awareness as the ability to recognise one’s self and relation to the world, and a model as a representation of some aspect of the world. In this context insight seems to reflect the extent to which one is awareness the *predictive value* of one’s self model and their ability to adjust their model based on error signals. Then you can see there are multiple different components that break down. For instance one could be highly self aware of the error signals they receive but misattribute them as in OCD. Another may not have awareness of the error signals at all and thereby continue with a model that has poor predictive value and be continually perplexed and likely distressed. Others may overfit and make new models to account for the errors. All of these are different ways in which insight can break down and would entail different approaches within that system to assist the person. But the question is from whose perspective to we judge the validity of the model and if it’s shared social reality it doesn’t necessarily follow this has the best predictive value.
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
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.
I meant a conscious, intentional process of developing a narrative. It is possible there may be something taking place at an unconscious neurological or psychological level that leads to psychosis. There are predictive processing theories of psychosis in which the brain processes of inference (that underlie perception and belief development) go awry or psychodynamic ideas of unconscious defense mechanisms. These are processes of a different sort than those involved in an individual exercising their autonomy.
My GP when she was sending me to my psychiatrist asked me "so how has your insight been" I replied that I didn't understand what she went, so she said "just say yes." Luckily she asked me to say yes
Then add to that all the noise of the term "anosognosia..."
https://www.peteearley.com/2018/03/12/anosognosia-is-it-an-accurate-description-of-a-person-who-doesnt-think-they-have-a-mental-illness/
Political implications aside, I don't think it's likely that neurological and psychological anosognosia are really comparable entities that it makes sense to collapse. The anosognosia of, say, someone who is manic and doesn't realize they're talking a mile a minute, seems more akin to what happens when someone gets irrationally angry and doesn't realize their compliants are unfounded, than what happens when someone has a stroke and can't tell that they are paralyzed. I think psychological anosognosia is contiguous with 'ordinary' brain function, albeit much more extreme, than what happens consequent to neurological injury. But that's informed more by experience and scientific intuition than research. It's on the long list of things I've been meaning to investigate further and maybe write about.
That's a very comprehensive approach to anosognosia, Dinah, and I appreciate your well-balanced concern about involuntary commitment. But I'd put more emphasis on psychiatry's use of terms like anosognosia to bolster our medical bonafides. To me, this speaks to the field's insecurity about its own status. And yes, I too wrote a blog post about this, over a decade ago:
http://blog.stevenreidbordmd.com/?p=443
I sometimes think we are too sure of ourselves in terms of what is right or wrong (isn't everyone in our polarized world?) and should question ourselves more. Nice to see you in yet another online venue, Steve!
Interesting post. I'm not sure your narrow notion of insight captures how it's routinely used in mental status exams, for patients with all types of symptoms. I've never experienced psychotic or manic symptoms but have been written about as lacking insight. At my medical school, we've been taught to evaluate all patients with regards to insight and that insight includes understanding the need for treatment. Perhaps this is why I was thought to lack insight - I thought the treatment they proposed would make me feel worse. As it turned out, I experienced hospital treatment as terrifying, coercive and humiliating and I have nightmares about it years later.
I am sorry you had to experience this! As I mention in the post, attitudes towards treatment are related to/a part of insight, but there are also many legitimate reasons for patients to disagree with a proposed course of treatment, and it is inappropriate and wrong to use the mere fact of treatment refusal as a sufficient reason to describe someone as lacking insight.
Great stuff. I appreciate your nuanced approach. I think we’re basically in agreement in terms of how we think about insight in actual practice. For me the most important aspect is someone’s ability to say “I’m unwell and I need help”, and everything after that is secondary. But I’m still not convinced that rejecting the “knowledge of the cause of illness” part is totally justified. Is your argument based on our currently incomplete scientific knowledge of mental illness, and therefore someday when our understanding is demonstrably better we could incorporate knowledge of causes into "insight”? Or is insight in principle separated from knowledge of the causes of illness (and if so, does that apply to non-mental illness too)? The latter option seems to imply that “insight” is purely a function of subjective sense-making and not about understanding something true about the world. If that's the case, I'd need to rethink my concept of insight from the ground up. But maybe I'm missing something important here?
I think knowledge of the cause of the condition is relevant to insight but also distinct from it. Consider, for example, a patient who has recovered from delusions and now says, “I recognize now that I was delusional. It is so strange that I believed all those things. I have heard from my friends that delusions are caused by the schizophrenogenic mother, and certainly, my mother was a harsh, mean woman.” You gently try to explain that science has discredited that hypothesis, but he shrugs and says it fits his experience so he will continue to believe it. A different patient recovers from delusions and says, “My imam tells me that psychosis is a punishment from God for one’s sins. May Allah have mercy on my soul.” It would be odd IMO to say that both these patients, who fully accept that they were delusional, lack “insight” into the delusions. Wouldn’t this put insight at mercy of scientific fads and changing attitudes? Does a person have insight if they say mental illness is a “chemical imbalance” or a “mitochondrial disorder”? At the same time, I accept that incorrect ideas about causation can be so wrongheaded and can be held with such conviction that they can become grounds for lack of insight.
That is, insight cannot simply be about parroting whatever bullshit story about causation some clinician tells the patient. And insight cannot be about scientific knowledge (just as IQ properly understood should not be about prior knowledge). There has to be some room for patients to possess insight and disagree with the clinician on how to interpret their experience.
Certainly insight isn't related to spouting back faddish theories—an addict on his umpteenth round of rehab or someone going through DBT can tell us the theories really well, but may have no ability to translate that into useful therapeutic change. But what if we extend the analogy to other illness? Granted we don't talk about insight into diabetes in the same way as mental illness, but it seems to me that between two patients, both of whom have diabetes and have constructed equally functional and adaptive narratives to manage it, if one of them actually understands the physiology of diabetes and the other patient has some fictional account of why sugar is bad, the one with the accurate account must have at least a bit more insight. In practice, though, for most illnesses having a knowledge of the causes will directly translate into managing the illness better, hence my thought that once we understand mental illness as well as we do diabetes or heart failure, then understanding the causes would become more important. I suppose genetics is one current example since some people take their genetics into account when deciding about children (eg not wanting to pass on some inherited family illness). If you don't know that most mental illness has some genetic component, you're missing a big part of the picture.
On the other hand there's also the issue of clinical context which you also got into. Seems clear to me that it is much more important for a patient with, say, chronic interpersonal problems to understand the true causes of those problems, eg the patient's own behavior which could be modifiable, than for someone with schizophrenia to understand nitty gritty details about the brain which, even if correct, isn't likely to affect his illness.
You raise some great points. An accurate understanding of the causes, to the extent they are known, is advantageous to one’s orientation towards the condition. And perhaps it is desirable for the concept of insight to reflect that in some manner. Need to chew on this more!
Good read.
It should be possible to discuss insight and lack thereof as a real thing, and simultaneously recognize that it's sometimes misused, and that there are some doctors who basically think "insight" means "agrees with me about everything".
Nice essay. It sort of started for me with Lewis’s statement sometime in the 1930s I vaguely recall but German Berrios and other learned and distinguished historians and practitioners established a much larger conceptual context and historical background. It fascinated me throughout my years in practice and your essay has caught some of the difficulties that I have had in pinning the concept down - it’s quite slippery, easily misunderstood, though very powerful in the intersubjective space between patient and therapist. Thank you.
I came on a refinement of self-knowledge which was a long time in the making. Since the related problems are so extreme, I believe mental health professionals couldn't identify a potential game changer. For one, the context in which they meet me, In a chair at an office, for that observational period, would make it impossible.
The key that picked the lock was when I noticed a level on which that addiction had infiltrated mundane tasks involving executive function. As I prepared food, I would go in and out of the room. Glancing at the computer screen for no reason. Then...
Just before or after I made a decision to buy some nicotine, my actions became more economical and more direct... purposeful looking activity.
The problem it may help: Since I was quite young, with almost no forewarning. I would have some level of frontal lobe over-activation.. It's very hard for me to cope with because i often involves memory and attentional impairment. I keep leaving treatment programs a couple of weeks in not really understanding why!
Now that I can spot this quirk of affect in the kitchen, I have physical and behavioral markers to give an ancillary cue to draw my attention.! That may seem insane, but I'll leave that to your clinical judgdement
I feel almost silly saying it. Among all the crazy behavior that would involve police, prisons and ambulances, a tiny change in how I cook when I thought of nicotine might be a lifesaver.
I found this a useful gathering of the ways "insight" is used. I share your view that the core meaning in the context of psychotherapy speaks to the level of the patient's capacity for introspection and self-awareness. In my practice, I've found that low-insight patients are not great candidates for more thoroughgoing psychoanalytic work (as Freud and others have emphasized). At least not initially. Because sometimes what appears as lack of insight, especially in more disturbed patients, turns out to be a defense...and once the defense is less needed, insight can start to develop. Thanks for your work.
Thanks very much, Ms. Wilbur. Yes: for me, the hallmark of serious illness/disease--in general medicine and psychiatry--is suffering and incapacity, as you well know. Thank you for sharing your experience. --Regards, Ron
We can think of the self as the first person model of one’s own agency, and awareness as the ability to recognise one’s self and relation to the world, and a model as a representation of some aspect of the world. In this context insight seems to reflect the extent to which one is awareness the *predictive value* of one’s self model and their ability to adjust their model based on error signals. Then you can see there are multiple different components that break down. For instance one could be highly self aware of the error signals they receive but misattribute them as in OCD. Another may not have awareness of the error signals at all and thereby continue with a model that has poor predictive value and be continually perplexed and likely distressed. Others may overfit and make new models to account for the errors. All of these are different ways in which insight can break down and would entail different approaches within that system to assist the person. But the question is from whose perspective to we judge the validity of the model and if it’s shared social reality it doesn’t necessarily follow this has the best predictive value.