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.
Premiere Date: April 20, 2021
Expiration Date: October 20, 2022
This activity offers CE credits for:
1. Physicians (CME)
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.1 Most clinical studies and empirical investigations of insight have focused on patients’ so-called psychological insight (sometimes referred to as clinical insight) and its role in the assessment and treatment of schizophrenia and other psychotic disorders. Since the early 2000s, the construct of cognitive insight has emerged as a complementary form and, like psychological insight, is considered to have important implications for research and clinical practice.2
Historically, assessment of patients’ psychological insight has played a prominent part in differential diagnosis, 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 psychotherapy 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.
Psychological and Cognitive Insight
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.2 Additional components include an appreciation of the social and related consequences of one’s illness.3 For the purpose of this discussion, psychological insight can be gauged by the criteria in Table 1.4
Table 1. Criteria for Psychological Insight1
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.5 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 Table 2.6
Table 2. Criteria for Cognitive Insight6
A Widespread Issue
Decreased insight is fairly common among patients with a broad range of mental health, neurodevelopmental, and neurocognitive disorders. 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.
What is generally referred to as impaired insight is prevalent among patients with schizophrenia, 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.7
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 nonadherence due to persistently impaired insight associated with a psychotic disorder, a long-acting injectable antipsychotic medication may be used to enhance adherence.8 Patients with impaired insight are also more responsive to supportive psychotherapy with distress tolerance and coping skills components than to insight-based psychodynamically oriented psychotherapy.
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.9
The Relationship Between Insights
Measures of psychological and cognitive insight correlate to a modest degree, suggesting that these 2 conceptualizations are relatively distinct (albeit overlapping) and complementary constructs.2
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.10 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 schizophrenia appear to have better awareness of some of their psychiatric symptoms than of their associated cognitive difficulties.7 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 mood problems.
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.1
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 neuropsychiatric symptoms.
For instance, a young adult with acute onset of a suspected substance-induced psychotic disorder may display a pattern of uniformly impaired insight, 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.
ANOSOGNOSIA. Psychological and cognitive insight overlap with the construct of anosognosia, which is defined as unawareness or denial of illness.11 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 neuropsychiatric status. Additionally, anosognosia might be extended to describe the insight-related difficulties of patients with neuropsychiatric disorders such as schizophrenia (Table 3).3
Table 3. Five Forms of Insight
PSEUDO-INSIGHT. 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 inpatient-level care, 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 narcissistic injury (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.12
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 stigma as a mediating variable, including what is referred to as self-stigma or internalized stigma.10 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. Alexithymia, which roughly translates to “no words for feelings,” involves a striking inability to make sense of and report one’s feelings.13 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 neuropsychiatric disorder(s) of varied type.
USABLE INSIGHT. 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 substance use disorders, because improved insight appears to contribute to better treatment outcomes.14
FEIGNED ILLNESS. 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.15 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.
An Etiology of Insight
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 psychosis.16
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 Alzheimer disease and the behavioral variant of frontotemporal neurocognitive disorder.17-19
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 schizophrenia and related disorders lacks clear empirical support and is not considered a sufficient explanation.7
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.
Correlates of Insight
Clinical literature and empirically based studies find many unfavorable consequences of impaired insight.2 Most of this literature pertains to psychological insight involving patients with psychotic disorders, in particular schizophrenia. Impaired insight has many negative consequences for patients’ mental health, careers, and social lives (Table 4).3,14,20,21
Table 4. Ramifications of Reduced Insight3,14,20,21
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 treatment adherence result in problems with insight?14
Regarding schizophrenia and psychological insight, there are positive correlations between higher levels of insight and greater adherence to treatment.14 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.22
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.2 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.23
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.24
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.23
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.22
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.23
Negative correlations have been reported between levels of psychological insight (specifically cognitive difficulties related to having a psychotic disorder) and degrees of neurocognitive impairment.25
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.2 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.2
Insight and the DSM-5
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, personality disorders, substance-related and addictive disorders, and neurocognitive disorders.26
Assessment and Tracking Tools
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.27 All have their strengths and weaknesses, and none are appropriate for all patients.
Most rating scales have been developed for the assessment of psychotic and related disorders 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.25
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.5
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.14
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 treatment adherence that may reflect heretofore unappreciated problematic insight.
Directions for Future Research
The clinical and empirical study of insight has largely been confined to psychotic disorders utilizing the construct of psychological insight. Therefore, considerably less is known about insight (both psychological and cognitive) in relation to mood and other disorders like obsessive-compulsive disorder.28 There are scant data bearing on the interface of insight with nonpsychotic disorders.
A key research agenda should include the development of empirically validated strategies to enhance cognitive and psychological insight across a range of disorders. Future research should help clinicians reliably differentiate state-related from trait-related decrements in insight. Promising interventions include psychoeducation (with both patients and caregivers), cognitive-behavioral approaches, motivational interviewing, and cognitive remediation.7,24,29
Future research should aim to better understand the therapeutics of insight, including whether specific interventions may be more effective in enhancing insight with certain patient groups. Further, it would be useful to understand which approaches may be more efficacious than others with certain components of impaired insight and during different phases of illness and stages of treatment.3,30
As for nonpsychotic disorders, it would be helpful to ascertain the base rates of compromised psychological and cognitive insight in these patients, and whether there are any clinically relevant differences in the level and pattern of insight-related difficulties between psychotic and nonpsychotic disorders and, more generally, across diagnostic categories.
To address these gaps in knowledge, it would be highly desirable to have clinician and patient rating scales that generate score profiles for both psychological and cognitive insight.
Rating scales that are germane to both forms of insight could help to determine whether measuring both at once would improve incremental validity. Multiple-form rating scales could contribute to more successful treatment planning and outcomes among one or more patient groups than rating scales that address only one type of insight.
Work groups tasked with the development of an updated DSM should consider inclusion of a clinical and research review of insight and its application to differential diagnosis.
Dr Pollak is a clinical and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, New Hampshire; and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, New Hampshire. He reports no conflicts of interest regarding the subject matter of this article.
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