Determination and Documentation of Insight in Psychiatric Inpatients

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.

CASE VIGNETTE

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.

CASE VIGNETTE

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?

 

What is already known about insight in psychiatric inpatients?

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.

 

What new information does this article provide?

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.

 

What are the implications for psychiatric practice?

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?”

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

Understanding insight

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”).

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 insight rating scales

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