The following case vignettes draw attention to the symptoms and signs of illness.
Anil is manic with mood-driven behaviors that are so out of control that he meets criteria for an involuntary hospitalization. Janice presents with psychosis—a delusion of impersonation, or Capgras syndrome. For both patients, a factor that will heavily influence treatment decisions, length of stay, medication adherence, need for extra support in the community—indeed the ultimate course of illness—is the patients’ level of insight.
Anil, a 20-year-old from India, now a college student in the United States, was involuntarily admitted to the psychiatric inpatient unit in a florid manic state, with rapid speech, flight of ideas, and sleeplessness. Before admission, he had been clocked driving at 100 mph. The intercepting police, noting his abnormal mental status, brought Anil to the emergency department. Mood stabilizer and antipsychotic medication settled him over a week, but he still persisted in believing the police “must have been drunk themselves,” since they assessed him as needing psychiatric help. “I’m not bipolar. Everybody has mood swings!” he insisted. He added, “I will take the medications while I am here, but I am not sure I really need them after I leave.”
Anil clearly does not accept the bipolar disorder diagnosis. Is this part of his illness and a sign that he is not yet stable? Should we trust him in a partial hospital or outpatient program or should he remain on a locked inpatient unit? In view of his lack of insight, does he need a change of medication? What should his family be told about his prognosis, especially if he persists in his denial of illness? Understanding insight is paramount for answering these questions.
Janice, a 27-year-old with schizophrenia, stopped taking her prescribed antipsychotic consistently. Within 2 months, her psychotic symptoms returned with full force, and she required hospitalization. She told the admitting psychiatrist that the woman who brought her to the emergency department was not her real mother, but rather “an actress playing her mother.” This misperception had likely played a role in threats she had made toward her mother on the day of admission. Questioned by the psychiatrist as to the plausibility of someone resembling her mother so precisely, she responded, “I don’t know how they did it, but somehow they were able to find someone!” A week after restarting her medication, Janice allowed that her imagination had been “playing tricks on her” and happily embraced her real mother.
Is Janice ready to go home after her week in the hospital? Does she really understand her illness well enough to be allowed to manage her own medications again? Does the risk of violence change the assessment? Should a long-acting injection be prescribed, given her history of nonadherence?
There is ample literature on insight in psychiatric patients, with much of it concentrating on severely ill inpatients. Insight scales have been used to explore the relationship of insight with various clinical conditions, situations, and outcomes in hospitalized patients.
Despite the considerable research literature on insight, little information has permeated to the clinical practice of psychiatry. This article reviews the relevant studies involving insight and offers an overview and critique of the various rating scales for insight.
Psychiatric assessments often give only cursory attention to the patient’s level of insight. This article provides practical tips for adding more detail to the assessment of insight in evaluations and progress notes. Improvement in insight assessments can help the clinician with important transitional stages in the patient’s treatment, including decisions around readiness for discharge and the level of monitoring required in the outpatient setting.
What’s insight got to do with it?
In written evaluations of psychiatric patients, many residents and attending psychiatrists include little nuance or detail on the insight component of the mental status examination. A review of initial psychiatric evaluations and progress notes shows that insight, often in a combined item listed as “Insight/Judgment,” is frequently described as “poor,” “fair,” “limited,” “improving,” etc. The use of these nonspecific adjectives can be attributed to time limitations and/or a desire for brevity. But these cursory terms also reflect the limited attention given to the assessment of insight in psychiatric training. After all, other, “sexier” elements of the mental status examination—thought content, thought process, mood, affect—are generally described more fully and with more specificity. Yet, a refined assessment of insight is equally important to the comprehensive patient evaluation, both on initial admission and on subsequent days. Simple adjectives do not capture the separate components of insight. The reader might reasonably ask, “poor insight into what?”
1. Cooke MA, Peters ER, Kuipers E, Kumari V. Disease, deficit or denial? Models of poor insight in psychosis. Acta Psychiatr Scand. 2005;112:4-17.
2. Dell’Osso L, Pini S, Cassano GB, et al. Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features. Bipolar Disord. 2002;4:315-322.
3. Marková IS. Insight in Psychiatry. Cambridge, UK: Cambridge University Press; 2005.
4. Schwartz RC, Cohen BN, Grubaugh A. Does insight affect long-term inpatient treatment outcome in chronic schizophrenia? Compr Psychiatry. 1997;38:283-288.
5. Rossi A, Arduini L, Prosperini P, et al. Awareness of illness and outcome in schizophrenia. Eur Arch Psychiatry Clin Neurosci. 2000;250:73-75.
6. Ghaemi SN, Rosenquist KJ. Is insight in mania state-dependent? A meta-analysis. J Nerv Ment Dis. 2004;192:771-775.
7. Yen CF, Chen CS, Yen JY, Ko CH. The predictive effect of insight on adverse clinical outcomes in bipolar I disorder: a two-year prospective study. J Affect Disord. 2008;108:121-127.
8. Peralta V, Cuesta MJ. Lack of insight in mood disorders. J Affect Disord. 1998;49:55-58.
9. Gharabawi GM, Lasser RA, Bossie CA, et al. Insight and its relationship to clinical outcomes in patients with schizophrenia or schizoaffective disorder receiving long-acting risperidone. Int Clin Psychopharmacol. 2006;21:233-240.
10. Lysaker P, Bell M. Insight and cognitive impairment in schizophrenia. Performance on repeated administrations of the Wisconsin Card Sorting Test. J Nerv Ment Dis. 1994;182:656-660.
11. Basil B, Mathews M, Sudak D, Adetunji B. The concept of insight in mental illness. Primary Psychiatry. 2005;12:58-61.
12. Pini S, Cassano GB, Dell’Osso L, Amador XF. Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features. Am J Psychiatry. 2001;158:122-125.
13. McEvoy JP, Freter S, Everett G, et al. Insight and the clinical outcome of schizophrenic patients. J Nerv Ment Dis. 1989;177:48-51.
14. Sanz M, Constable G, Lopez-Ibor I, et al. A comparative study of insight scales and their relationship to psychopathological and clinical variables. Psychol Med. 1998;28:437-446.
15. Kay SR, Fiszbein A, Opfer LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13:261-276.
16. David AS. Insight and psychosis. Br J Psychiatry. 1990;156:798-808.
17. McEvoy JP, Apperson LJ, Appelbaum PS, et al. Insight in schizophrenia. Its relationship to acute psychopathology. J Nerv Ment Dis. 1989;177:43-47.
18. Appelbaum PS. Clinical practice: assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357:1834-1840.
19. Carsky M, Selzer MA, Terkelsen K, Hurt SW. The PEH. A questionnaire to assess acknowledgment of psychiatric illness. J Nerv Ment Dis. 1992;180:458-464.
20. Amador XF, Strauss DH, Yale SA, et al. Assessment of insight in psychosis. Am J Psychiatry. 1993;150:873-879.
21. Amador XF, Flaum M, Andreasen NC, et al. Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry. 1994;51:826-836.
22. Beck AT, Baruch E, Balter JM, et al. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res. 2004;68:319-329.
23. Colis MJ, Steer RA, Beck AT. Cognitive insight in inpatients with psychotic, bipolar, and major depressive disorders. J Psychopathol Behav Assess. 2006;28:242-249.
24. Tait L, Birchwood M, Trower P. Predicting engagement with services for psychosis: insight, symptoms and recovery style. Br J Psychiatry. 2003;182:123-128.
25. Marková IS, Roberts KH, Gallagher C, et al. Assessment of insight in psychosis: a re-standardization of a new scale. Psychiatry Res. 2003;119:81-88.