Deficits in insight have implications for numerous clinical inpatient hospitalization issues, including the decision to hospitalize a patient voluntarily or involuntarily in the first place. Other insight-related issues include adherence to treatment after discharge, guardianship/capacity assessments, readiness for discharge decisions, the choice of oral medications versus long-acting depot medication, recommendations for placement in a structured setting after discharge, and the referral of patients to appropriate psychotherapy on hospital discharge.
The etiology of lack of insight has been variously conceptualized as1:
• Stemming from neuropsychological (brain) deficits
• Part of the primary psychiatric illness itself (eg, poor insight as a symptom of mania)
• A form of defensive denial protecting the patient against the distress of awareness of illness
Regardless of the theoretical model—and it is likely that all apply in different circumstances—the assessment of insight should be detailed and well documented in the clinical record.
A sizable group of clinical researchers, within both psychology and psychiatry, have studied and clarified the concept of insight and its application to clinical states. There is abundant literature on the design and validation of rating scales of insight, and there are studies that correlate deficits in insight with psychiatric diagnoses and with various states of illness.2,3
A moment’s insight is sometimes worth a life’s experience.
—Oliver Wendell Holmes Jr
Impaired insight is intrinsic to many, if not most, severe psychiatric conditions. Poor insight is a prevalent feature of schizophrenia, and lack of awareness of schizophrenic symptoms is correlated with poor medication adherence and higher rates of recidivism.4,5 Poor insight is also common in bipolar disorder, and although insight is more state-dependent in bipolar disorder than in schizophrenia, it correlates with poor treatment outcomes.6,7
Poor insight in mania is not necessarily related to the presence or absence of psychotic symptoms.8 Multiple studies have shown correlations between poor medication adherence and lack of insight across diagnostic groupings.3 Assessment of insight has a pivotal role in the decision to give a psychotic patient a long-acting depot medication.9
Finally, recent research has expanded into the neuropsychological underpinnings of insight. For instance, the literature suggests that insight deficits in schizophrenia show a greater correlation to the degree of cognitive impairment than to acute psychopathology.10
In a general context, meanings assigned to insight generally combine some metaphorical use of terms related to seeing and perception, or words that imply comprehension and self-knowledge. For instance, synonyms for the word “insight” include vision, understanding, awareness, intuition, perception, acumen, comprehension, discernment, and perceptiveness. To illustrate this further, one needs only to note that “insight-oriented psychotherapy” and “insight therapy” are often used interchangeably with other terms for psychodynamic therapies, eg, psychoanalytic psychotherapy, psychodynamically oriented psychotherapy, and even “uncovering therapy.” The insight gained in these therapies can be considered a product of working through of psychological conflict and a concomitant awareness of the self that was previously preconscious or unconscious (the dictionary’s “glimpse or view beneath the surface”).