[Principles of insight and relations between insight and control].
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Dangerous Behavior↗
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The curative and creative aspects of insight.
Insight is a sine qua non of the psychoanalytic process and is a condition, catalyst, and consequence of the psychoanalytic process. Analytic insight is defined and differentiated from other types of self-knowledge and awareness and from pseudo insight; there are different levels and underlying processes in the development of insight. The importance of insight is delineated in theory and therapy, in analyst and patient, and in psychoanalysis and psychotherapy. Psychoanalysis aims to minimize noninsightful influences and to maximize insight leading to structural change. Psychoanalysis is not without a goal, but has the inexorable goal of expanded insight. Clinical limitations to gaining and retaining insight are recognized. Stress is placed on the acquisition and creation of insight and its relation to ego development, analytic progress, and adaptive mastery. Insight and creativity are complementary, and insight has creative and novel configurations. Although it is organized and consolidated in conscious verbalization, insight may proceed outside awareness. An unnoticed case of Freud's provides an example of creative insight. The achievement of insight effects and reflects structural change. Clinical psychoanalysis maximizes insight and minimizes other therapeutic influences.
Adaptation, Psychological↗
Insight and symptom change in schizophrenia and other disorders.
OBJECTIVE: This study sought to evaluate levels of insight and change in insight in subjects with schizophrenia and other major psychiatric disorders. This study also evaluated the relationship of insight to acute psychopathology. METHOD: One-hundred and eighty-seven subjects consecutively admitted to an acute care psychiatric unit and who met DSM-III-R criteria were evaluated by the Insight and Treatment Attitudes Questionnaire and Brief Psychiatric Rating Scale on admission and discharge. Relationships of insight to diagnosis, involuntary commitment status and change in insight were evaluated with analysis of variance and post hoc Tukey's Standardized Range test. Relationships of change in insight and symptoms were evaluated with analysis of covariance (ANCOVA) and correlation. RESULTS: Insight deficits were more prevalent in schizophrenia, a mixed group of other psychosis and bipolar disorder as compared with major depressive and schizoaffective disorder. Committed patients had lower insight. Insight improved across diagnoses during hospital care in both voluntary and committed patients. Significant relationships between improved symptoms and improved insight were obtained in the bipolar, schizophrenia and major depressive groups. CONCLUSION: Insight deficits are prevalent in schizophrenia and bipolar disorder. Many patients show improved insight as their acute symptoms improve. Some aspects of insight are state related during exacerbation of illness in patients with schizophrenia and bipolar disorder.
Acute Disease↗
The dynamics of insight in the prodrome of schizophrenia.
INTRODUCTION: Schizophrenia is characterized by diminished insight, which fluctuates with disease progression. Insight deterioration in the prodrome of schizophrenia is poorly understood. Despite pharmacologic treatment, including early interventions, there is a high risk of relapse and need of acute care in schizophrenia patients. OBJECTIVE: To study if insight deterioration occurs during the prodrome and if insight preservation early in the illness might predict a better prognosis. METHODS: Data was collected retrospectively from the records of 24 patients initially diagnosed with schizophrenia during a 2-year period. Patients' progress was then tracked over a 3-year period. Insight was determined by a physician's subjective evaluation, patient interest and participation in treatment planning, and patient accuracy in reporting behaviors and symptoms when compared with reports from collaterals. RESULTS: Ten patients were determined to have insight regarding the developing illness at different presentations at the hospital. Insight preservation correlated with less need for emergency visits and fewer hospitalization days (P<.005). It was also associated with more depressive and anxious mood (P<.000). Patients and family members described early, ego-dystonic perceptual disturbances followed by diminished insight. Awareness into the illness, symptoms, and attribution of symptoms to the illness fluctuated at different presentations in the insight group. In the other group, insight was nil at each presentation after the psychotic debut. CONCLUSION: Most patients maintain insight during the perceptual disturbance phase. Insight diminishes as the early delusional phase sets in. Higher levels of preserved insight seem to correlate with less need for acute treatment. Further research in this area is warranted for determining if early insight oriented interventions in the prodromal phase can improve the prognosis of schizophrenia.
Adult↗
Insight and correlates among outpatients with depressive disorders.
The aims of this study were to explore the levels of insight in patients with depressive disorders and to examine the factors that influenced insight. Using the Mood Disorders Insight Scale, we evaluated 247 patients with depressive disorders to determine their levels of insight with respect to their awareness of the illness, the attribution of symptoms, and their belief in the necessity of treatment. The relationships between insight and the severity of depressive symptoms, the level of self-stigma, sociodemographic characteristics, and the course of the illness were examined. The results reveal that 91 (36.8%) subjects had impaired insight into awareness of their illness, 92 (37.2%) had impaired insight into attribution of symptoms, and 39 (15.8%) had impaired insight into the need for treatment. A younger age and more severe depression symptoms were significantly associated with insight into awareness of the illness. More severe depression symptoms and a higher education were associated with intact insight with respect to attribution of symptoms. Those who have a major depressive disorder were more likely to have intact insight into the need for treatment than those with depressive disorder that was not otherwise specified. Analysis of our results indicates that depressive patients with factors predicting impaired insight may benefit from intervention to improve their insight, and this should advance their recovery.
Adolescent↗
Insight in first-episode psychosis.
BACKGROUND: We report here a study examining the relationships between insight and psychopathology, cognitive performance, brain volume and co-morbid depression in 251 patients experiencing a first episode of psychosis, who were then randomly assigned to 2 years of double-blind treatment with either olanzapine or haloperidol. METHOD: Repeated measures of insight were obtained at baseline and 12, 24, 52 and 104 weeks by the Insight and Treatment Attitudes Questionnaire (ITAQ). RESULTS: Older age, female gender and white ethnicity were associated with more insight. Higher total, positive, negative and general psychopathology scores on the Positive and Negative Syndromes Scale (PANSS) were associated with less insight. Higher depression scores were associated with more insight. Better neurocognitive function and large brain volumes were associated with more insight. More insight throughout the study was associated with longer time to medication non-adherence. However, baseline insight was not significantly related to the probability of discontinuing the study before 2 years. Insight improved significantly over the course of the study, but the improvement in insight was not significantly different between the two antipsychotic treatment groups. CONCLUSIONS: Multiple factors contribute to insight. Patients experiencing a first episode of psychosis who have little insight are at increased risk of discontinuing their medication.
Adolescent↗
The association of insight with psychotic symptoms, depression, and cognition in early psychosis: a 3-year follow-up.
Recent research has begun to examine the level of insight following a first episode of psychosis since this may have implications for outcome. Insight was investigated in 278 individuals consecutively admitted to a comprehensive early psychosis treatment program. Insight, symptoms and cognition were assessed on admission and after one, two and three years. Sixty percent had good insight at baseline and this improved significantly to 80% at one year. Insight remained good at years 2 and 3 with 78.6% and 82.8%, respectively, having good insight. A comparison of those with good to those with poor insight revealed that at each assessment point those with poor insight had significantly higher ratings on positive, negative and general psychopathology symptoms (all at p<0.001). Additionally those with good insight had significantly higher levels of depression at baseline (p=0.001). With respect to cognition when using a composite cognitive factor there was a significant advantage for the good insight group at one year (p=0.01). Overall results show that a significant proportion of individuals have good insight following a first episode of psychosis. For this group depression may be a significant concern at least upon initial presentation. Those with poor insight have increased symptoms throughout the first three years and possibly poorer cognitive functioning.
Adolescent↗
Correlates of insight among patients with bipolar I disorder in remission.
BACKGROUND: The aims of this study were to explore the levels of insight in a group of bipolar patients in remission and to investigate factors related to capacity for insight. METHODS: Using the Schedule of Assessment of Insight (SAI) and its expanded version (SAI-E), we interviewed 65 patients with bipolar I disorder in remission to determine their levels of insight. Multiple regression analysis was used to examine the factors that influenced insight. RESULTS: Our results revealed that most of our bipolar subjects had fair or good insight, though some residual insight impairment was still observed. Multiple regression analysis revealed that being male, having a shorter duration of illness and having psychotic features predicted poorer insight in two dimensions of SAI and SAI-E, accounting for 18.6-23% of the variance. LIMITATIONS: The six independent variables used in these multiple regression could only account in part for the variance of insight, indicating that there must be other variables that influence insight of bipolar patients in remission. CONCLUSIONS: These results indicated that bipolar patients with the factors predicting poor insight should possibly receive interventions to improve their insight and advance their recovery.
Adolescent↗
Insight and prefrontal cortex in first-episode Schizophrenia.
Few studies have investigated the neurobiological basis of impaired insight in antipsychotic-naive schizophrenia. However, the relationship between insight and specific prefrontally mediated cognitive functions suggests that insight deficits may be an expression of prefrontal cortical dysfunction. This study was designed to examine the relationship among insight, neurocognition, and dorsolateral prefrontal cortex (DLPFC) volumes in first-episode antipsychotic-naive schizophrenia subjects. DLPFC volumes were compared between 35 first-episode schizophrenia subjects with good (n = 17) and poor insight (n = 18). Morphometric measurements were based on MRI scans by trained raters blind to clinical information. First-episode schizophrenia subjects with poor insight showed decreased right DLPFC volumes relative to those with good insight. In addition, those with poor insight had higher levels of perseverative errors (PEs) on the Wisconsin Card Sort Test (WCST). No differences in other neuropsychological measures were found between the good and poor insight groups. Similarly, no differences were found between schizophrenia subjects with good versus poor insight on any of the psychopathological measures employed in this study. These findings suggest that poor insight in schizophrenia may be a function of specific prefrontally mediated neurocognitive deficits rather than a global impairment in neuropsychological functioning or different profiles of psychopathology.
Adult↗
Insight in seasonal affective disorder.
Lack of insight complicates the evaluation and treatment of patients with psychotic and affective disorders. No studies of insight in seasonal affective disorder (SAD) have been reported. Thirty patients with SAD diagnosed by the Structured Clinical Interview for DSM-III-R but no other axis I conditions were treated short-term with light-therapy. Insight was measured with the Scale to Assess Unawareness of Mental Disorder (SUMD) as modified by the authors to assess the self-report of insight into depressive symptoms. Increasing scores (1 to 5) indicated increasing unawareness of illness (i.e., less insight). SAD patients displayed a moderate amount of insight when depressed (mean SUMD score, 2.5). When recovered, they showed no significant change in insight into past depressive symptoms (mean SUMD score, 2.8). Greater insight into current depressive symptoms correlated with more depressive symptoms on the Hamilton Rating Scale for Depression score ([HRSD] r = .35, P < .05). In conclusion, SAD patients possess a moderate amount of insight into depressive symptoms that does not change after recovery, a result in agreement with studies of insight in psychosis and mania. Further, in SAD, increased severity of illness may be associated with increased insight into depressive symptoms, consistent with the hypothesis of depressive realism.
Adult↗
Lack of insight in mood disorders.
BACKGROUND: The study's aim was to examine insight in mood disorders in relation to type of mood episode, psychotic state, and insight change over the episode. METHODS: Fifty four patients with a manic or major depressive episode were interviewed for insight assessment at admission and discharge. RESULTS: At admission, mania patients had more severe insight impairment that depressive ones, depressive patients with psychosis had poorer insight than those without psychosis, and mania patients had poor insight irrespective of the presence of psychotic symptoms. At discharge some insight impairment was observed in mania. CONCLUSION: Lack of insight was a prevalent condition in psychotic depression and mania. LIMITATIONS: A global insight measure was used. Ratings of insight were not blind to the ratings of other symptoms. CLINICAL RELEVANCE: Considering residual insight impairment in mania may be important to maximize compliance and to prevent relapse.
Adult↗
Insight and its relationship to clinical outcomes in patients with schizophrenia or schizoaffective disorder receiving long-acting risperidone.
Poor insight is common in schizophrenia, predictive of non-compliance, and an impediment to effective patient management. We hypothesized that long-acting risperidone would be associated with enhanced insight, contributing to improved quality of life measures. In an international, open-label 50-week study, stable patients received long-acting risperidone every 2 weeks. Assessments included the Positive and Negative Syndrome Scale [PANSS; item G12 rated 'impaired insight and judgment' from 1 (no impairment) to 7 (severe impairment)]; Clinical Global Impressions-Severity (CGI-S); and the Medical Outcomes Study Short-form 36-item Health Survey (SF-36) (patient-rated quality of life). Correlation and regression post-hoc analyses examined associations between insight and other measures. At baseline, 314 (51.1%; N=614) patients had impaired insight (G12=3-7) and 83 (26.4%) achieved normal or near normal ratings at endpoint (G12=1-2). Symptom severity corresponded with insight: baseline mean+/-SD PANSS total scores were 56.0+/-14.4 in patients without impaired insight (G12=1-2); 73.4+/-15.7 with mild-moderate impairment (G12=3-4); and 86.0+/-17.4 with severe impairment (G12=5-7). These scores improved significantly in each group at endpoint (P<0.001). Improved insight ratings correlated with improvements in CGI-S (r=0.37); PANSS disorganized thought (r=0.46); negative symptoms (r=0.32); and anxiety/depression (r=0.24; P<0.001 all comparisons), but not quality of life ratings. The change in insight did not contribute significantly to the variance in SF-36 scores; however, changes in negative symptoms, anxiety/depression and CGI-S scores did contribute significantly. Long-acting risperidone was associated with improvements in insight, symptom domains, clinical status and quality of life measures. Associations were noted between patient-rated quality of life and specific symptom domains, but not insight.
Adolescent↗
Insight in clinical psychiatry. A new model.
Recent interest in insight in psychiatry has resulted in studies focusing on correlations between insight and variables such as severity of psychopathology, neuropsychological impairments, and magnetic resonance imaging. However, there has been relatively little exploration of the concept of insight itself as a basis of empirical research. This paper examines the concept of insight, differentiating this from the phenomenon of insight, and proposes that insight is a construct that needs to be considered from the perspective of the patient, of the clinician, and of their interaction. A new hierarchical model of insight construction is described, closely linked to symptom formation, and mechanisms are suggested to explain insight structure in relation to the different ways symptoms arise. The relationship between insight and symptom structure and disease suggests that the phenomenon of insight will vary in relation to different diseases. This in turn suggests that insight assessments should be modified according to the individual disease.
Attitude to Health↗
Is insight in mania state-dependent?: A meta-analysis.
In the first meta-analysis of studies assessing insight in mania, we sought to determine whether insight in mania is state-dependent or a trait-like condition. In schizophrenia, insight is a trait-like condition. If state-dependent, insight in mania would differ from insight in schizophrenia, and different treatment and research implications would follow. Seven reports using standardized insight rating scales in mania were identified through a MEDLINE literature search. Four longitudinal studies were included in a meta-analysis. The meta-analysis found that insight appears to be state-dependent. Insight showed a 20% improvement (95% confidence intervals, 7% to 34%) after recovery from acute mania (p = .003). Insight improves in bipolar disorder with resolution of the acute manic episode, suggesting that insight is state-dependent in bipolar disorder. We suggest that impaired insight be considered as part of the diagnostic picture of acute mania.
Awareness↗
Beliefs, feelings and insight of patients with schizophrenia about taking medication.
There has been little systematic study of the attitude of clients with schizophrenia toward treatment, specifically about taking medication. This study measured the attitude of 100 clients with schizophrenia toward taking their medication in the hospital. They include 47 males and 53 females ranging in age from 18 to 75 years (mean = 33). Interviews occurred on the 1st to 32nd hospital day (mean = 4). Fishbein's expectancy-value model provided the theoretical base for this study. Both open-ended and fixed-response estimates of attitude were made. Insight was measured, and the relationship between insight and attitude and between hallucinations and insight were analysed. Age and sex were evaluated in order to determine their effects, if any, on attitude. Internal consistency of both the fixed-response instruments and the insight instrument was evaluated. Clients were able to provide information about beliefs and feelings about taking medication and about insight into illness and treatment. Attitudes varied tremendously; clients frequently held both strongly positive and strongly negative beliefs at the same time. The range for the fixed-response estimate of attitude was -52 to +76; the range for the open-ended estimate was -84 to +24. However, the instruments were significantly correlated (r = 0.5640, P = less than 0.000). Clients also varied widely in their insights with some having good insight and some having poor insight. The insight instrument correlated with the fixed response instrument (r = 0.2585; P = 0.005) suggesting that insight may be related to positive attitude. Attitudes were not affected either by age or sex. Insight was negatively affected by hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Assessment of insight in psychosis.
OBJECTIVE: It is frequently reported that patients with psychotic disorders have poor insight into their illness. Previous research has suggested that poor insight may have considerable power in predicting the long-term course of chronic mental disorders and an impact on patients' compliance with treatment plans. The authors, proposing that insight is best viewed as a multidimensional phenomenon, developed the Scale to Assess Unawareness of Mental Disorder, which samples discrete and global aspects of insight across a variety of manifestations of illness. This article reports on a reliability and validity study of the scale. METHOD: The study subjects were 43 patients with schizophrenia and schizoaffective disorder. Various aspects of insight into illness were evaluated with the scale. In addition, ratings of psychopathology, course of illness, and compliance with treatment were made. RESULTS: Item variability was high and normally distributed, supporting the authors' contention that insight can be rated on a continuous rather than dichotomous scale. Results of the analyses examining the relations between the various dimensions of insight assessed and the psychopathology, course, and compliance variables were generally as hypothesized. Convergent validity with other global measures of insight was found, and aspects of poor insight were correlated with poorer compliance and course of illness. Examination of the interrelations among the four insight subscales revealed that these subscales sample independent phenomena. CONCLUSIONS: The Scale to Assess Unawareness of Mental Disorder has good reliability and validity and has certain advantages over previous measures of insight, suggesting the usefulness of a multidimensional view of this complex concept.
Adult↗
Lack of insight in psychotic and affective disorders: a review of empirical studies.
In patients with psychotic or affective disorders, lack of insight is often a vexing clinical problem. However, it has infrequently been subjected to formal study. We have reviewed clinical psychiatric studies on insight in psychotic and affective disorders, selecting those that evaluated insight for each patient and presented the data in some quantitative fashion. Almost all studies focused on schizophrenia, with little research present on affective disorders. Definitions of insight varied among studies, as did diagnostic methods and other measures. Despite these limitations, several conclusions emerged. First, insight is not a unitary entity but has several dimensions, such as insight into symptoms and insight into need for treatment. Second, although insight may be poorer in patients with more-severe psychopathology, it does not always improve when psychopathological symptoms do. Third, insight is associated with medication compliance, prognosis, voluntary versus involuntary admission, and cultural concepts of disease. Fourth, insight into illness, need for treatment, or delusions may respond to cognitive and psychoeducational methods of treatment. To augment these findings, we suggest further avenues of research on insight.
Culture↗
[Relationships between insight and medication adherence in subjects with psychosis].
BACKGROUND: Poor medication adherence in subjects with psychosis has a high prevalence and a negative impact on clinical outcome. Several studies have reported that a poor level of insight was a strong predictor of poor medi-cation adherence. However, few studies have investigated whether insight was associated with medication adherence, independently from other clinical and treatment characteristics. OBJECTIVE: To explore the link between insight and medi-cation adherence in subjects with psychosis, and to assess the impact of potential confounding factors on this association. METHOD: Subjects included in the study were patients aged 60 or less, consecutively admitted in a psychiatric ward, and presenting with at least one psychotic symptom (delusion or hallucination). Medication adherence was assessed using: 1) history of total discontinuation of treatment against medical advice over the 2 weeks before admission; 2) the 7-point rating scale developed by Kemp et al.; 3) the self-report questionnaire Drug Attitude Inventory (DAI). The Scale to assess Unawareness of Mental Disorder (SUMD) was used to measure level of insight. Assessment of symptoms was performed using the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), and the Calgary Depression Scale (CDS). DSM IV diagnoses were assessed using the Diagnostic Interview for Psychosis (DIP). The associations between level of insight (SUMD scores) and the three measures of medication adherence were explored using the non-parametric Mann-Whitney and Spearman's tests. Logistic regression models giving Odds Ratios (ORs) and 95% confidence intervals (95% CI) were used to examine the impact of potential confounding variables on the associations between level of insight and medication adherence. RESULTS: 42 patients presenting with schizophrenia broadly defined (n=25) or psychotic mood disorder (n=17) were assessed. Significant associations were found between higher SUMD scores (ie poorer insight) and discontinuation of treatment before admission (z=- 2.6, p=0.009), poor medication adherence rated using the Kemp et al.'s scale (r=- 0.64; p=0.0001), and negative perception of treatment assessed using the DAI (r=- 0.405; p=0.009). The Kemp'scale score and the DAI score were categorised into poor vs. good according to the median for logistic regression analyses. Subjects were 1.7 times more likely (OR=1.7, 95% CI 1.1-2.5, p=0.01) to have discontinued their treatment, 1.9 times more likely (OR=1.9, 95% CI 1.3-2.8), p=0.0003) to have poor medication adherence rated with the Kemp's scale, and 1.8 times (OR=1.8, 95% CI 1.2-2.6, p=0.005) more likely to have a negative perception of the treatment for one point increase at the SUMD score (ie lower level of insight). The associations between SUMD score and the three measures of medication adherence were not modified after adjustment for demographic characteristics (age, gender, educational level, occupational status, marital status) and categorical diagnosis (schizophrenia broadly defined vs. psychotic mood disorder), severity of symptoms (SANS, SAPS, CDS scores), characteristics of the psychotropic treatment, diagnosis of substance or alcohol use disorder, age at onset, and number of previous admissions. CONCLUSION: The study demonstrates that medication adherence is associated with the level of insight, independently from other patient's demographic and clinical characteristics. The association between low level of insight and poor medication adherence should be confirmed using prospective studies carried out in ambulatory patients. These findings suggest that psycho-educational programs aimed at improving insight should be developed in order to improve medication adherence.
Adult↗