In contrast to the more comprehensive psychoanalytic concepts, insight has a more circumscribed meaning in the psychiatric mental status examination, especially with severely ill inpatients. In this context, insight refers to awareness of one’s current psychiatric condition or illness, the ramifications of said illness, attribution of the cause of illness, and appreciation of the need for treatment.11 This emphasis on insight into illness is especially fitting in the more severe mental disorders, since much of the research, including the development and validation of rating scales, has centered on schizophrenia, bipolar disorder, dementia and, to a lesser extent, depression.3,8 Some insight rating scales, which are reviewed in the following section, have only been fully validated for psychotic states.
Patients with Axis II disorders are frequently admitted to acute inpatient units, but the concept of insight in this group is considerably less developed in the general psychiatric insight literature. Assessment of insight in patients with personality disorder can be related to psychodynamic concepts of ego-dystonic and ego-syntonic character traits. Defense mechanisms are also important to consider, since lower-level defenses such as splitting, projection, and externalization lead to the patient’s distorted views of the treatment team, poor recognition of internal emotional states, and lack of awareness of his or her own role in the difficulties that led to hospitalization.
Standardized scales of insight have been used in the research setting but are not currently used in common clinical practice. The majority of practicing psychiatrists may not even be aware of the myriad scales that have been developed and validated. Scales are widely used to evaluate levels of insight across various stages of illness, because insight relates to extent of brain pathology (eg, dementia) and correlates with treatment outcomes.11-13 Although too time-consuming to administer to every patient, a well-chosen insight rating scale could be useful for formally documenting a patient’s insight deficits. Even informally, awareness of the types of questions found on these scales allows a more meaningful assessment of insight than the current general practice in the hospital setting (Table 1).
Sanz and colleagues14 concluded that there are considerable correlations among the scales; this indicates the construct validity of the concept of insight. Marková3 provides a comprehensive and detailed account of the scales, including historical, philosophical, and clinical dimensions of the entire concept of insight and analysis of the virtues and shortcomings of various insight ratings. Many rating scales are available with which to assess a patient’s insight. The following 7 scales may be useful on the acute psychiatric unit (Table 2).
Item G12. Part of the General Psychopathology section of the Positive and Negative Syndrome Scale (PANSS),15 Item G12 (lack of judgment and insight), is used separately as an insight scale. The PANSS was developed for use in patients with schizophrenia, and it measures severity of illness and subsequent improvement in trials of new antipsychotic medications. Similar to the other PANSS items, Item G12 is rated on a 7-point scale ranging from “Absent” to “Extreme.” “Mild” applies to patients who recognize their illness but downplay its seriousness and the need for ongoing treatment, ie, have a “mild” lack of insight. “Extreme” applies to patients with blanket denial of illness, delusional interpretation of hospitalization, and lack of cooperation with treatment staff. Item G12 is closely tied to awareness/acknowledgment of psychiatric illness and the need for treatment. Although formally validated in patients with schizophrenia, the anchor points of item G12 can also describe other psychotic illnesses, including severe manic states.
While Item G12 provides brevity and ease of administration, it is neither comprehensive nor practical. However, because it is so brief, this scale could be used at several points during an inpatient admission as a gauge of improvement in insight during the course of treatment.