Jerrold Pollak, PhD

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this article is to provide an overview of psychological and cognitive insight, including working definitions for these and other insight-related constructs. The etiologies of compromised insight are outlined. This article also highlights clinically relevant correlates of psychological and cognitive insight.

1. Clarify the similarities and differences between psychological insight and cognitive insight

2. Identify and define different types of pseudo-insight

3. Review common etiologies of compromised insight

4. Discuss the role of rating scales and psychological/neuropsychological testing in the evaluation of insight

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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The evaluation of patients’ insight into their own conditions has been a cornerstone of psychiatric practice for more than a century.

 Most clinical studies and empirical investigations of insight have focused on patients’ so-called psychological insight (sometimes referred to as 

) and its role in the assessment and treatment of schizophrenia and other psychotic disorders. Since the early 2000s, the construct of 

 has emerged as a complementary form and, like psychological insight, is considered to have important implications for research and clinical practice.

Historically, assessment of patients’ psychological insight has played a prominent part in 

, case formulation, treatment planning, and decision-making. It has been considered an integral component of the mental status examination, intake evaluations, progress/treatment notes, and case closing summaries.

Since the advent of the stress tolerance and coping skills era of 

 in the early 1990s, the construct of insight has played a less significant role in diagnosis and treatment planning. Still, the construct of insight remains an important factor to consider when utilizing a stress tolerance and coping skills approach to assessment and psychotherapy.

The reality is that there is no consensus definition for psychological insight. Broad and vague definitions are vulnerable to subjective judgment, low inter-rater reliability, and a high number of false positives, resulting in the overdiagnosis of insight-related problems. Narrower definitions risk generating unacceptably high rates of false negatives. This can lead to underdiagnosis of both the level and the severity of impaired insight and the erroneous conclusion that a patient has enough insight to benefit from a range of treatment options.

From a historical perspective, 3 components stand out: awareness that one has a mental disorder, the ability to correctly attribute one’s symptoms to this condition, and the capacity to appreciate the need for treatment.

 Additional components include an appreciation of the social and related consequences of one’s illness.

 For the purpose of this discussion, psychological insight can be gauged by the criteria in 

Table 1. Criteria for Psychological Insight

Cognitive insight, unlike psychological insight, is a relatively recent arrival in the literature and has its genesis in the work of Aaron Beck, MD, and colleagues.

 Cognitive insight comprises 2 components: self-reflection and self-certainty. The former refers to considering competing perspectives and entertaining alternative explanations for one’s beliefs, ideas, and perceptions. The latter is the ability to be self-critical with respect to the correctness of one’s beliefs, ideas, perceptions, and reasoning process. Self-certainty also includes a willingness to modify one’s conclusions about self and others in response to support and empathetic feedback. Criteria for cognitive insight are included in 

Decreased insight is fairly common among patients with a broad range of mental health, neurodevelopmental, and 

 Decrements in psychological and cognitive insight are associated with a number of difficulties for patients, their loved ones, and the practitioners involved in their care. Insight-related difficulties also have significant implications for diagnosis, case formulation, and treatment. In addition, clinicians need to carefully assess the adequacy of a patient’s level of psychological and cognitive insight in order to facilitate decision-making regarding informed consent to treatment, civil commitment, mandated outpatient treatment, child custody, parental fitness, work capacity, criminal responsibility, legal guardianship, estate planning, and assisted suicide.

, major mood disorders, and psychotic disorders. Although estimates vary, it seems at least 30% of these patients have compromised insight, which adversely affects their judgment and decision-making, response to treatment, functioning, and quality of life, as well as the attitudes and feelings of significant others.

Insight might impact treatment choices, including level of care, alliance building, choice of treatment modalities, treatment adherence, and the overall course and outcome. For example, if a patient has a history of 

 due to persistently impaired insight associated with a psychotic disorder, a long-acting injectable antipsychotic medication may be used to enhance adherence.

 Patients with impaired insight are also more responsive to supportive psychotherapy with distress tolerance and coping skills components than to insight-based psychodynamically oriented 

As well, both psychological and cognitive insight figure prominently in psychoeducation for caregivers and nonpsychiatric health care providers regarding the psychosocial and medical needs of patients with diminished insight.

Measures of psychological and cognitive insight correlate to a modest degree, suggesting that these 2 conceptualizations are relatively distinct (albeit overlapping) and complementary constructs.

Cognitive insight differs from psychological insight because of its emphasis on meta-cognitive capacities and, more specifically, the patient’s capacity for cognitive flexibility. These considerations encompass patients’ awareness of the possible fallibility of their perceptions, beliefs, ideas, and thinking processes. It also includes the ability to hear corrective feedback and then use it to correct the maladaptive reasoning that underlies faulty conclusions about oneself and others.

Moreover, because cognitive insight includes the ability to entertain alternative explanations or viewpoints, it may ultimately undergird psychological insight. As patients’ cognitive insight increases, they should be more aware of their illnesses and recognize salient symptoms and their real-world impact. In this regard, both of these types of insight may work in tandem to enhance self-understanding and treatment responsiveness.

Both psychological and cognitive insights are best understood as complex and interdependent multidimensional phenomena on a continuum and, hence, should be viewed as nonbinary.

 Therefore, the question is not whether a patient possesses or lacks psychological or cognitive insight, but rather to what degree, if at all, they demonstrate self-awareness. In this regard, patients can have adequate or better insight into one or more aspects of their condition but not others.

For example, there is evidence that patients with 

 appear to have better awareness of some of their psychiatric symptoms than of their associated cognitive difficulties.

 Or, a patient may have a very limited understanding of the significance of their psychotic symptoms and decline intervention, but may be painfully aware of their depression and receptive to treatment for 

Thus, clinicians should use their estimation of a patient’s psychological and cognitive insights to create both a case-specific profile of strengths and weaknesses germane to psychological self-reflection and an estimation of the patient’s ability to work in a reasonably productive manner in treatment.

Psychological and cognitive insight are dynamic rather than static constructs. A patient’s insight profile may change over time in response to medical, psychological, and situational influences. A patient’s insight may also fluctuate due to the frequency, duration, type, and severity of 

For instance, a young adult with acute onset of a suspected substance-induced psychotic disorder may display a pattern of uniformly 

, but within a few days of supportive and targeted psychiatric treatment, the same patient may demonstrate substantial improvement on one or more insight components or parameters. Conversely, if a patient has waxing and waning insight-related difficulties due to a major mood disorder with intermittent psychosis and then suffers mild head injuries, they may exhibit a more widespread, persistent, and severe profile of impaired insight, referable to postconcussive factors. Therefore, it is important to periodically reevaluate the adequacy of insight.

Psychological and cognitive insight overlap with the construct of anosognosia, which is defined as unawareness or denial of illness.

 This term is generally limited to the detrimental effects of medical conditions that impair central nervous system functioning and adversely affect a patient’s ability to recognize symptoms and their neurologic causes. It also has negative effects on daily functioning and quality of life. Problems with psychological and cognitive insight are considered an integral part of a patient’s 

. Additionally, anosognosia might be extended to describe the insight-related difficulties of patients with neuropsychiatric disorders such as schizophrenia (

This refers to patient reports suggesting greater recognition and understanding of their clinical status than is warranted based on history, collateral information, everyday functioning, recent/current life circumstances, and clinical judgment.

In some instances, pseudo-insight represents a form of positive impression management. Patients may display pseudo-insight when seeking greater autonomy from real or perceived control by family or caregivers. Successful impression management can sometimes lead to quicker discharge from 

, reduced involvement or termination of outpatient services and mental health court, and the voiding of conditional discharges from state hospitals.

In extreme cases, pseudo-insight can be associated with iatrogenic effects. This can occur when caretakers attempt to achieve quicker and more substantial gains in self-understanding than can be realistically assimilated and productively utilized, leading to a potentially serious worsening of the patient’s clinical status.

Patients with psychotic disorders and personality disorders associated with a susceptibility to 

 (and accompanying precipitous loss of self-esteem, rage, dissociation, or transient psychosis) are especially vulnerable to destabilization in response to premature or overzealous efforts of clinicians to bolster insight. In particular, patients with borderline personality disorder are highly prone to negative therapeutic reactions, although this can also be observed in patients with other problematic personality patterns.

Pseudo-insight can also be a problem after an initial psychotic episode, when patients may experience postpsychotic depression (anxiety, depression, lowered self-esteem, increased hopelessness, suicidal preoccupation, and reduced subjective quality of life). A mix of true and pseudo-insight often accompanies and influences this phase. It has also been tied to the pernicious influence of 

 as a mediating variable, including what is referred to as self-stigma or internalized stigma.

 Postpsychotic depression is often accompanied by a mix of accurate insight into one’s condition and pseudo-insight. The pernicious influence of stigma may be a mediating variable here, notably what is referred to as “internalized stigma.”

There is also a variant of pseudo-insight that may be more aptly termed “deceptive insight,” which involves persuasive and seemingly illuminating self-disclosures, frequently coupled with observations of others, that aim to manipulate and exploit others. Patients with salient antisocial or psychopathic traits frequently exhibit this form of pseudo-insight.

 Alexithymia, which roughly translates to “no words for feelings,” involves a striking inability to make sense of and report one’s feelings.

 It is characterized by severe lifelong difficulty recognizing, labeling, describing, and expressing affective states, including psychological symptoms and other mental status change. These individuals have a characterological form of impaired insight, which may be aggravated by psychosocial or other stressors. It may worsen in response to the onset of 

This concept refers to insight that flows from an ongoing treatment that is perceived as supportive and nonthreatening. It can be productively used by the patient to achieve desirable, real- world goals while maintaining hope for continued symptomatic and functional improvement. This insight has received increased attention in the literature on recovery trajectories in psychotic disorders. It potentially has broad application to many other psychiatric conditions, including 

, because improved insight appears to contribute to better treatment outcomes.

 Feigned illness involves an exaggerated and, in some instances, fabricated account of poor daily functioning secondary to psychiatric or medical disorders. It can include reports of difficulties or symptoms that are compatible with impaired insight.

 This clinical presentation appears to reflect “negative impression management.” These patients may receive a diagnosis of malingering, when the motivation involves one or more external incentives, or of a factitious disorder, when the sick role is a salient motivating factor.

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness. In many cases, limitations in insight are associated with long-standing neurodevelopmentally based cognitive and neuropsychological deficits, the onset of neurocognitive deficits during the prodromal psychotic phase, or a first episode of 

In the case of anosognosia, reduced insight can result from an acute or insidious medically induced mental status change, referable to central nervous system dysfunction. This includes an acute mental status change referable to a right hemisphere cerebral vascular accident, which has well-documented negative effects on insight, and the deleterious effects of progressive neurodegenerative diseases such as 

 and the behavioral variant of frontotemporal neurocognitive disorder.

Impaired insight may also result from psychosocial or other stressors, which can heighten the effect of long-standing psychological defenses and associated coping strategies. That said, this explanation for diminished awareness of illness in 

 and related disorders lacks clear empirical support and is not considered a sufficient explanation.

Two or more etiologies can have a synergistic effect. For instance, an older adult with significant personality disorder, primarily involving one or more insight-interfering defenses (eg, denial, omnipotence, externalization of blame, projection, and/or projective identification), might develop a neurodegenerative disorder, which is also associated with diminished insight. In these circumstances, it is easy to misattribute the limitations in insight to the neurologic disorder. In fact, the patient’s long-standing problematic defensive structure and coping mechanisms may be a contributory factor or even a sufficient explanation for the insight-related difficulties. This is not rare, especially early in the neurodegenerative disease process.

Along similar lines, limitations in insight frequently co-occur as part of the long-term baseline functioning of patients with neurodevelopmental disorders such as intellectual disability and autism spectrum disorder, even when these conditions are mild. Kindred conditions, like borderline intellectual functioning, are also highly associated with baseline decrements in insight. In some instances, this can lead to an overdiagnosis of an acquired impairment in insight.

A reliable history (via record review or collateral interviews with significant others) that includes neurodevelopmental status, personality patterns and traits, and general adaptation to life preceding illness onset is needed to determine the root cause of a patient’s impaired insight. Reports of previous psychological and neuropsychological test evaluations can also be helpful.

Clinical literature and empirically based studies find many unfavorable consequences of impaired insight.

 Most of this literature pertains to psychological insight involving patients with 

, in particular schizophrenia. Impaired insight has many negative consequences for patients’ mental health, careers, and social lives (

Table 4. Ramifications of Reduced Insight

These negative consequences make intuitive sense and continue to influence clinical practice. However, there is only modest empirical support for many of them. Moreover, most of the research study data are correlational and, hence, insufficient to clearly establish cause and effect relationships. For example, is poor treatment adherence caused by decrements in insight or do difficulties with 

Regarding schizophrenia and psychological insight, there are positive correlations between higher levels of insight and greater adherence to treatment.

 Higher insight also correlates with improved indices of general mental health and better daily functioning over time. On the other hand, there are negative correlations between lower levels of insight and increased frequency of positive and negative psychotic symptoms, greater disorganized thinking, and increased rates of psychiatric hospitalization.

Additional empirical research on psychological insight is indicative of mixed findings regarding insight and indices of quality of life and functioning. Results have included both positive or negative correlations and no linkages between insight and these variables.

Empirical research on cognitive insight has found negative correlations between the self-reflectiveness component of cognitive insight (an indicator of higher cognitive insight) and positive symptoms of psychosis.

 Notably, these symptoms are more frequent among patients with lower self-reflectiveness. Findings are also consistent with the expected linkage between the self-certainty component of cognitive insight (an indicator of lower cognitive insight) and positive symptoms of psychosis, which are more frequent among patients with higher self-certainty. There are mixed findings regarding the relationship between cognitive insight and indices of quality of life and adequacy of daily functioning.

There is a continuously expanding body of research on the cognitive and neuropsychological correlates of insight. As is true with most other research endeavors pertaining to insight, the most widely studied form of insight is psychological insight. Most investigations have involved patients with schizophrenia and related psychotic disorders.

With few exceptions, most studies of patients with schizophrenia report significant and persistent decrements in cognitive and neuropsychological functioning that encompasses general 

cognitive and intellectual abilities and skills

, sustained attention and concentration, anterograde-episodic memory, and executive functioning.

Still, patients’ neurocognitive profiles show considerable heterogeneity, and small numbers of patients with schizophrenia have minimal or no discernible neurocognitive deficits based on detailed psychometric testing.

Cognitive and neuropsychological functioning should be related to the adequacy of psychological insight. That is, better neurocognitive functioning should be correlated with higher levels of insight, and worse neurocognitive functioning should be linked with lower levels of insight. Overall, studies offer reasonable evidence for this prediction and support the idea that cognitive and neuropsychological deficits are meaningfully related to decrements in accurate self-appraisal.

Still, the linkages are far from robust. This suggests that neurocognitive factors are probably not sufficient to explain the high base rates of impaired insight in schizophrenia and psychotic disorders. This underscores the importance of adopting a biopsychosocial perspective when it comes to understanding the relationship of insight to schizophrenia and other mental disorders, and when considering the development of effective strategies to augment insight.

Negative correlations have been reported between levels of psychological insight (specifically cognitive difficulties related to having a psychotic disorder) and degrees of neurocognitive impairment.

Finally, a review of the correlates of cognitive insight found fairly good support for an association between higher levels of self-certainty and worse neurocognitive functioning.

 That review also highlights mixed findings when it comes to the expected positive correlation between the self-reflectiveness component of cognitive insight and neurocognitive functioning (namely, that higher levels of self-reflectiveness are associated with better neurocognition). More specifically, higher self-reflectiveness was associated with more compromised neurocognition.

An innovative feature of the DSM-5 is the introduction of specifiers, which are designed to provide a more fine-grained description of a patient’s diagnostic status. A specifier for insight is based on the following classification: good or fair insight, poor insight, and absent insight or delusional beliefs. This specifier is indicated for 3 of the 9 disorders contained in the chapter titled “Obsessive-Compulsive and Related Disorders.” It remains unclear why only 3 diagnoses and this category of disorders have these specifiers, because many DSM-5 categories include conditions that can present with varying degrees of problematic insight, including neurodevelopmental disorders, dissociative disorders, somatic symptoms and related disorders, feeding and eating disorders, 

, substance-related and addictive disorders, and neurocognitive disorders.

There is no gold standard assessment protocol or tool(s) for evaluating insight, but there are a number of self-report and clinician rating scales that have been developed since the 1990s.

 All have their strengths and weaknesses, and none are appropriate for all patients.

Most rating scales have been developed for the assessment of 

 and are not clearly applicable to patients with suspected or known decrements in insight. Some scales measure a limited number of components of awareness, judgment, and thinking germane to insight. For example, the Measure of Insight into Cognition-Clinician rating scale is specifically designed to assess insight related to cognitive difficulties and symptoms in patients with schizophrenia.

Similarly, many scales are not designed for longitudinal assessment over the course of treatment. Some are geared more to one form of insight than another. For example, the Beck Cognitive Insight Scale is designed for the assessment of cognitive insight, whereas most scales were developed for the evaluation of psychological insight.

Scales for the assessment of psychological insight intercorrelate reasonably well, which suggests that they are measuring comparable aspects of this construct. However, correlations between self-report and clinician and observer scales are modest, indicating that there are important discrepancies between patient self-appraisal and clinician judgment regarding insight.

Unfortunately, the majority of these instruments have, at best, a limited normative base. Many do not have operational criteria for classifications based on level of severity (eg, impaired/poor, fair, good), which would strengthen interscorer reliability. Moreover, few instruments generate empirically derived cut-off scores for classifications (normal versus abnormal, impaired versus intact) or involve score profiles offering clear guidelines for diagnosis and treatment planning and intervention.

Self-reported rating scales are not stand-alone instruments and should only be used to supplement findings from clinician-based rating scales, clinical and semi-structured interviews, and collateral data from record reviews and informants. Clinical judgment is needed to properly utilize these scales for diagnosis, treatment planning, and longitudinal assessment.

It may be necessary to perform formal psychological and neuropsychological testing. These tests include self-reporting instruments such as the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), the Personality Assessment Inventory (PAI), and the Million Clinical Multiaxial Inventory-IV (MCMI-IV). They contain scales and indices relevant to the assessment of insight (including pseudo- and deceptive insight). Formal psychological and neuropsychological testing should be considered when the patient’s clinical status remains unclear following appropriate assessment or when there is some question about personality and psychodynamic or cognitive and neuropsychological factors that contribute to the patient’s insight-related difficulties/symptoms. Formal testing might also follow repeated unexplained stalemates in treatment or difficulties with 

 that may reflect heretofore unappreciated problematic insight.

Articles

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness.

Earn CME Credit by learning more about psychological and cognitive insight.

Psychological and Cognitive Insight: How to Tell Them Apart and Assess for Each

Modern medicine has achieved considerable success in containing and, in some cases, eradicating epidemics of debilitating and lethal infectious illness. In recent decades there has also been significant progress in the prevention, diagnosis, and treatment of major psychiatric disorders. Yet, major psychiatric illness 

highly associated with significant morbidity and mortality.

 Suicide is among the most frequent lethal outcomes of major psychiatric illness.

Since the start of this century, suicide rates have increased dramatically across the age range. Among the many disturbing trends, the suicide rate among pre-adolescents and younger adolescents has increased 178% from 2007 to 2017. During this period the incidence of suicide has increased 76% among older adolescents.

 Suicide is now a formidable public health epidemic.

Evidence-based harm reduction suicidology has arisen in response to this alarming development. This conceptual framework emphasizes the importance of prevention, by restricting access to lethal means and through psychoeducation, including reducing stigma and heightening public awareness of prodromal and/or warning signs. It also involves risk assessment screening and/or evaluation and case formulation, as well as safety and treatment planning. Finally, this approach includes strategic outreach to patients and their families, offering timely access to care that is specifically tailored to the needs of the suicidal patient. The goals of programs based on this model include improved safety, reduced risk, and amelioration of comorbid medical and psychiatric conditions that contribute to elevated risk.

 is a complex multi-determined biopsychosocial phenomenon, and the suicidal patient remains an elusive 

 for effective prevention, identification, and intervention.

Substantial barriers to suicidal harm reduction remain. At-risk patients have a high incidence of concurrent mental illness, personality disorder, and substance abuse. They are often beset by difficult and seemingly intractable life circumstances. The considerable demoralization and hopelessness that characterizes a substantial percentage of patients at risk for suicide contributes to a high level of skepticism and mistrust of the mental health care system and reluctance to engage and remain in treatment. This constellation of difficulties has a negative impact on efforts to reduce death by suicide.

Formal risk assessment, a cornerstone of contemporary evidence-based clinical practice, is notoriously unreliable with respect to predictive validity, regardless of approach and thoroughness. It generates low hit rates: unacceptably high rates of false positives and false negatives.

 Moreover, there are mixed findings with respect to the efficacy of safety planning in reducing the incidence of suicidal behavior.

Despite the recent developments in evidence-based suicidology, which include several promising risk assessment models and diagnostic tools, suicide remains unpredictable in each case. Consequently, many patients with concerning risk factors for serious self-harm are discharged from inpatient, outpatient, and emergency department settings. Psychiatrists and other mental health specialists. keep their fingers crossed that this turns out to have been a reasonable decision and that the patient remains safe—at least in the short term.

, which is the most well-known and influential harm reduction initiative to date. This training and consultation program is a multipronged effort to incorporate best practices from evidence-based suicidology as outlined above. It has successfully integrated these practices in ways which are relatively easy for psychiatrists and other health care professionals to learn and execute. It has made a substantial contribution to improving the standard of care for suicide prevention, evaluation, and treatment.

Fostering hope while not raising unrealistic expectations regarding outcome should be a key objective of any public health care initiative. Regrettably, the term Zero Suicide implies the perfect outcome of irrevocably eliminating suicide. At the same time the literature promulgated on Zero Suicide states only in passing that this is an aspirational goal but is otherwise silent as to its attainability. Despite this quiet qualification, the very name Zero Suicide implies that suicide is a condition that can be eradicated, much like some infectious disease epidemics, and that this is the ultimate objective of this program.

Suicide, however, is a very different societal ill then the 

 of this century. Advances in medical technology and treatment have significantly curtailed these diseases. Unfortunately, there is no evidence that methods can be devised that would entirely eliminate suicide, despite the powerful human need to attain maximal control over existential threats.

The moniker of Zero Suicide runs the distinct risk of raising false hope for patients, their loved ones, and their health care providers. Suicide assessment and treatment, for the foreseeable future, is likely to continue to be more art than science. Advances in suicidology may well succeed at lowering the incidence of suicide, perhaps even on a sustained basis, but are quite unlikely to eliminate it.

There is a substantial evidence regarding the negative effects of patient suicide on loved ones and their health care providers. These include potentially destabilizing and protracted feelings of anxiety, depression, anger, loss, shame, guilt, and failure.

 One can only hope that the concept of Zero Suicide does not have the unintended consequence of exacerbating these reactions in people who have lost someone to suicide by virtue of its utopian vision of a society free from death by suicide.

The developers and promoters of Zero Suicide need to rethink their brand and consider that such a title, although uplifting in some respects, is also misleading. A name change would be highly desirable, one that reflects a greater appreciation for the unrelenting human penchant for self-destruction but also instills hope that evidence-based research and practice can eventually result in better outcomes. Short of a name change, the literature on Zero Suicide ought to include a clear and unequivocal statement that the goal of this initiative is limited to finding increasingly effective ways to save lives by sharply reducing the occurrence of suicide, but not trying to extirpate it.

The views expressed in this article are those of the author and do not necessarily reflect the opinions of

 is a clinical and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, NH; and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, NH. He reports no conflicts of interest regarding the subject matter of this article.

This article was originally posted on September 18, 2020, and has since been updated. Scroll down for the 

Premature mortality across most psychiatric disorders

2. Frankl R. Suicide deaths rising in children 10-19 years. 

3. O’Connor RC, Nock MK. The psychology of suicidal behavior. 

4. Murray D, Devitt P. Suicide risk assessment doesn’t work. 

. March 28, 2017. Accessed September 17, 2020. 

https://www.scientificamerican.com/article/suicide-risk-assessment-doesnt-work

5. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revised: 10-year systematic review. 

6. Milner A, Witt K, Pirkis J, et al. The effectiveness of suicide prevention delivered by GPs: a systematic review and meta-analysis. 

7. Miller IW, Camargo CA Jr, Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. 

8.Stanley B, Brown GK, Brenner LA, et al. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department. 

9. Gutkin NJ. Losing a patient to suicide: what we know. 

A well-meaning mental health initiative may be setting unrealistic expectations.

What’s in a Name: The Problem with Zero Suicide

    Based on the “normal curve,” the distribution of various psychological characteristics in the general population, nearly 23 out of 100 individuals can be classified as having below average intellectual functioning-IQ’s that range from 70 to 89 but fall above what is generally considered mild mental retardation. 
    Borderline Intellectual Functioning is a significant correlate and risk factor for the development of a broad spectrum of neuropsychiatric disorders treated by psychiatrists and, more specifically, is quite common among patients with autistic and psychotic spectrum disorders.

 It is also a significant risk factor for less favorable treatment outcomes. As well, it is a robust predictor of limited educational/vocational attainment and is associated with persistent problems with adaptive coping.
    Psychopharmacologic interventions may need to be modified in keeping with the reduced cognitive capacities of these patients. In many cases, certain interventions may be contraindicated, including some forms of psychodynamically-based psychotherapy. 
     Many patients with Borderline Intellectual Functioning can be expected to have difficulty comprehending the rationales for various treatment plans/recommendations, leading to lowered adherence/compliance. Hence, treatment interventions in this subpopulation should be modified to take into account the cognitive limitations of Borderline Intellectual Functioning.
     Because of its high prevalence within various neuropsychiatric groups and potential for significantly affecting treatment planning and outcome, the 

 Task Force should consider removing Borderline Intellectual Functioning as a V code and including this designation as a possible separate axis, specifier, and/or part of a “dimension” germane to cognitive competence/disability.
     When in doubt about such a designation in a particular case, referral to a psychologist for cognitive/neuropsychological testing and assessment of adaptive capabilities/functioning would be appropriate. 
 


1. Frances A. Advice to DSM-V: Change deadlines and text, keep criteria stable. Psychiatric Times. 2009;XXVI:1,7-8.
2. Wechsler D, Coalson DL, Raiford SE. WAIS-IV technical and interpretive manual. San Antonio, Texas, Pearson; 2008.
3. Harvey, P, Keefe R. Clinical neuropsychology of schizophrenia. In: Grant I, Adams K, eds. Neuropsychological Assessment of Neuropsychiatric and
Neuromedical Disorders. New York, Oxford, 2009;507-522.

Borderline Intellectual Functioning is rarely included in clinical reports and case/treatment team reviews except indirectly when, as part of the mental status examination, mention is sometimes made that the patient’s intellect appears to fall below average limits.

Jerrold Pollak, PhD

Articles

Psychological and Cognitive Insight: How to Tell Them Apart and Assess for Each

What’s in a Name: The Problem with Zero Suicide

A Call to DSM-V to Focus on the Designation of Borderline Intellectual Functioning