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    S6-1. Insight in Clinical Psychiatry A New Model

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    Oliver CR

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    © All Rights Reserved
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    serosa zac Coppi © 1006 y Wis Wiki Vol. 18, No.2 Print U8 Insight in Clinical Psychiatry A New Model IVANA S. MARKOVA, MB, CB, M.RC-Psvcut, aND GERMAN B. BERRIOS, B.A (Oxox),, M.D., FRCPstcit, FBPSS! Recent interest in insight in psychlatry has resulted in studies focusing on correlations: ‘between insight and variables such as severity of psychopathology, neuropsychological im- pairmenis, and magnetic resonance imaging. However, there has been relatively litte explora lion of the concept of insight itself as a basis of empirical research. This paper examines the ‘concept of insight, differentiating tis from the phenomenon of insight, and proposes that Insight is a constrict that needs to be considered from the perspective of the patient, ofthe clinician, and of their interaction. A new hierarchical model of insight construction is de- scribed, closely linked to symptom formation, and mechanisms are suggested to explain insight structure in relation to the different ways symptoms arise. The relationship between insight and symptom structure and disease suggests that the phenomenon of insight will vary in relation to diferent iiseases. This in turn suggests that insight assessments should be ‘modified according to the individual disease. In spite of recent interest in insight and its assess- ‘ment, its overall meaning in psychiatry remains unclear (Amador et al., 1991; Birchwood et al, 1994; Cuesta and Peralta, 1994; David, 1990; Markova and Berrios, 1992a; Takai et al, 1992; Vaz et al, 1994). A similar difficulty is encountered in psychology (Sternberg and Davidson, 1995), philosophy (Lonergan, 1957), and neu- ropsyehology (Prigatano and Schacter, 1961), where insight has been explored alongside notions such as consciousness, self nowledge, and intuition. In psychi- ary, insight has been conceptualized from various per. spectives (¢g., gestalt, psychodynamic, phenomenolog ical) so that its meaning and assessment in relation to mental illness vary accordingly (for a history of insight, ‘see Berrios and Markova, in press-a) ‘The assessment of insight as part of the mental state ‘examination requires a clear definition, Generally taken to refer to the knowledge and/or understanding the patients have of their illness, insight is gauged on the basis of patients’ verbal declarations and behaviors However, it is not altogether clear: a) what depth of knowledge is required to ascertain its presence, ) whether understanding refers to the illness/disease af: fecting the patient or to specific symptoms; and e) what, mechanisms are involved in the process of “having” or “not having” insight Etymology and semantic history show that the con: ceptualization of insight, like that of consciousness, remains based on a visuoperceptual metaphor. The writers of the Ozford English Dictionary (Second Ed “Department of Psychiatry, Unversity of Cambridge, Adden ‘rooke'sHosplal, Box 19, Hills Road, Cambridge, United Kingdom, ‘Send reprint request to Dr. Beri. 43 J Nerv Ment Dis 189:743-751, 1996 tion) correctly comment: “The original notion appears to have been ‘internal sight,’ ie., with the eyes of the ‘mind or understanding. .. but subsequently there arose a tendency to analyze the word as sight or seeing into a thing or subject, although even so there usually re- mained the notion of penetrating into things or seeing beneath their surface with the eyes of the understand- ing.” The aim of this paper is to review the concept of insight in clinical psychiatry, differentiating between this and the phenomenon of insight. A new model of insight structure is also proposed, and some of the issues and implications that arise from the empirical translation of the model and its application to clinical practice are discussed. It is worthwhile stressing at the outset that while such a model of insight will be principally explored in relation to mental symptoras and diseases, our fundamental assumption is that in- sight into illness is not governed by a different modular mechanism, Indeed, it would be uneconomical from the point of view of evolution for such a specialized system to evolve, It is far more likely that the same ‘mechanisms underlie the appraisal of any and all expe- riences, whether “normal” or “pathological.” Current Research Review of empirical studies on insight in clinical psy- chiatry shows a mixed picture. This has been described {in detail elsewhere (Markové and Berrios, in press) and only some of the relevant points will be summarized here. First, the definitions of insight and methods by Which it is assessed are variable, making it difficult to draw valid conclusions or make meaningful compari m4 MARKOVA AND BERRIOS sons. In general, approaches used in the assessment of insight can be divided into a) categorical, i. insight fs viewed as an allornone phenomenon (described as present or absent) or categorized into more groups (described as being present, partially present, or ab- sent), and b) continuous, ie, insight is conceptualized asa continuous process and assessed in terms of scores from structured schedules based on a unitary concept (McEvoy et al, 19804) or on multidimensional models ‘(Amador et al, 1901; David, 1900 Problems beset the categorical approach. A common ‘one is that anchor points such as fll, partial, or absent ae rarely defined, as in Bskey (1958), Heinrichs eta (1986), Van Putten et al (1976), Cuesta and Peralta (1904), and Takal et al. (1982), where more or less structured methods of mental state examination were ‘used but the scalar criteria were not specified, Further- more, the categorization approach is based on narrow definitions of insight, generally couched in terms of recognition/awareness of mental illness, with some adding awareness of the need for treatment. (De- pending on the design of the study, the inclusion of “treatment awareness” makes subsequent correlations with “treatment compliance” tautologica.) Narrow de- fnitions ental a view of insight as a “discrete entity” or “symptom” that is not semantically coterminous with the idea of “awareness,” with which it is often combined. ‘The dimensional approach, on the other hand, has endeavored to broadden and operationalize the assess- rent of insight. McEvoy etal. (1980a) devised the In- sight and Treatment Attitude Questionnaire to assess patients’ awareness of their illness and perceived need for treatment and hospitalization, This standardized in- strument yields insight scores but is based on a fairly narrow definition of insight and focuses on the degree of correlation between attitudes of patients and staff rather than on patients’ subjective views. More re- cently, some have viewed insight as “multidimensional” (Amador et al, 1991; David, 1900; Greenteld et al., 1989), i, as consisting of related dimensions suscepti- bleto assessment and quantification by standard sched- ules. Thus, David (2990) proposes three dimensions: awareness of mental illness, awareness of the need for treatment, and the ability to relabel psychotic experi- ences as abnormal. Amador et al (1991), on the other hhand, suggest a broader multidimensional construct of insight as comprising:a) awareness of the signs, symp: ‘toms, and consequence of illness, b) general attribution about ilness and specific attribution about symptoms and their consequences, ) seléconcept formation, and 4) self-defensiveness. In their empirical work, however, Amador et al. (1998) base their assessment of insight on different dimensions, namely, awareness of ness (general and particular symptoms), attribution regard- ing illness and symptoms, achieved effects of medi- cation, and awareness of the social consequences of hhaving a mental disorder. They also include retrospec- tive views, ‘These are important and interesting studies but they also highlight some of the difficulties surrounding the concept of insight. Itis not clear, for example, on what basis dimensions are developed andor selected out of a larger poo! of possible dimensions. In addition, there is a need for further exploration of the relationship between such dimensions and the meaning of insight, and the extent to which they can capture clinically some of the theoretical aspects of insight ‘Most empirical studies on insight focus on the rela- tionship between “levels” of insight and factors such as prognosis (Amador et al, 1993; Bskey, 1958; Hein- richs eta, 1985; McBvoy etal, 1989b), treatment com- pliance (Bartké et al, 1988; Lin et al, 1970; Marder et al, 1983; McEvoy et al., 1989b; Van Putten et al, 1976), and severity of psychopathology (Amador et al 1908; Amador et al, 1004; Cuesta and Peralta, 1904; David et al, 1992; Heinrichs etal, 1985; Markov and Berrios, 1992; MeBvoy etal, 1980a, 1963; Michalakeas et al, 1904; Takai et a, 1982; Vaz et al, 1994). More recently, correlations have also been sought between ‘degree of insight and neuropsychological impairments (Cuesta and Peralta, 1994; MeBvoy etal, 1983; Young et aL, 1993) or magnetic resonance imaging (Takai et 1962). Results are variable and inconsistent: for exam ple, some studies have suggested that insight is not related to prognosis (Eskey, 1958; Van Putten et al, 1976), while others suggest that increased insight re- lates to better outcome (Amador et al, 1993; Heinrichs etal, 1985; MeBvoy etal, 19890). Sill others indicate 8 more complicated relationship with outcome, eg, Roback and Abramowitz (1979) showed in their study that while increased insight was related to improved Dpehavioral adjustment, it was at the same time related to increased subjective distress. The relationship be- tween insight and severity of psychopathology is like- wise unclear and inconsistent (Amador and Strauss, 1993; Markova and Berrios, in press). Some studies Indicate that degree of insight is related to severity of psychopathology (David et al, 1992; Markova. and Berrios, 1992; Michalakeas et al, 1994; Tala etal, 1902); others disagree (Cuesta and Peralta, 1994 Hein- richs etal, 1085; McEvoy etal, 1080a, 1998; McGlashan and Carpenter, 198D), yet others believe that such a relationship is significant only in relation to specific symptoms oF symptom clusters (Amador etal, 1993; 1904; Heinrichs et al, 1985; Vaz etal, 1994). Putative relationships between insight and treatment. compli- ance have been considered as strong (Bartk6 et al, 1988; Lin et al, 1979; Marder et al, 1983; McEvoy’ et al, 1985b) and weak (Van Potten et al, 1976), and INSIGHT IN cl some have even suggested a negative effect of treat- ment on insight (Whitman and Duffey, 1961). Siailarly, ‘while David et al. (1992) found that insight correlated positively with 1Q (assessed by the NART), Takal etal. (1992) found no correlations between insight and 1Q (assessed by the WAIS). Likewise, conflicting results are found in studies correlating insight with neuropsy- chological tests. Thus, MeBvoy etal. (1998) and Cuesta ‘and Peralta (19944) found no relationship between in- sight and neuropsychological tests; indeed, the latter authors reported an association between poor insight and better performance on some of the subtests. On the other hand, Young et al. (1993) found a significant correlation between lack of insight and neuropsycho- logical performance. It is clear, therefore, that empirical studies yield mixed and confusing results which are likely to be due in part to the differences in definitions of insight and the ways in which insight is assessed, The most im- portant issue emerging from this review isthe need for more conceptual work before further empirical work is undertaken. Furthermore, current researchers tend to deal exclusively with psychotie patients: but surely, to have any meaning insight must be seen as an aware- ness function assessable in other conditions, such as obsessive-compulsive disorders, hysteria, dementia, and depression ‘The Phenomenon of Insight Ontoiooy Atthis stage, itis important to clarify the terminology. used in relation to insight. The phenomenon of insight refers to the appearance or manifestation of insight in clinical terms. There are two main aspects to consider in relation to this definition. First, from an ontological perspective, the phenomenon of insight, whether refer ring to normal or pathological experiences, has to cor- respond to or represent. some real entity. In other words, it is assumed that there is something called “insight” that exists in reality, and that this is mani- fested as the phenomenon of insight. At this point, i snot necessary to commit oneself to the level of defint- tion of such reality, be it described in terms of brain receptors, signals, networks, ete. It sulces to say that the phenomenon of insight is supervenient upon some form of physical reality. (Supervenience is used here in the technical sense put forward by Davidson in 1970, that “mental characteristics are in some sense depen- dent, or supervenient, on physical characteristics” [Kim, 1993]. Treating the phenomenon of insight as supervenient upon some sort of reality is correct but not very helpful from an empirical point of view. The very nature of the concept suggests that it reflects a process that pervades all experiences, and that it might INICAL PSYCHIATRY 5 >be impossible simultaneously to capture al its kaleido- scopic appearances. Nor would it be possible to take into account all the situations, actual or potential, where insight might be apparent in relation toa particu lar experience, not least because of additional inter- acting factors such as time and contexts that must af- fect the expression of insight. Epistemology This leads to the second aspect in which the phenom enon of insight can be considered, namely, from an epistemological perspective. In this sense, the phenom- enon of insight, rather than being viewed as something that is actually happening, can be considered as that, ‘hich is being presented or assessed clinically. In other words, this has more to do with the relationship be tween what is happening and the way in which itis clinically conceived. Thus, the phenomenon of insight, from the epistemological viewpoint, can be regarded as representing only contingent. and particular aspects of the phenomenon of insight in its ontological sense. It is in the epistemological sense that the term “ nomenon of insight" is used in this paper. ‘The Concept of Insight ‘To complicate matters further, we must discuss the “concept” of insight. Elsewhere (Markové and Berrios, in press), we have argued for a distinction to be made between the concept of insight and the phenomenon of insight, where the concept refers to the broader frameworks upon which the phenomenon may be based. In the light of the above discussion, this needs to be clarified further. Detailed psychological (Komatsu, 1992; Medin, 1989; Smith, 1988) and philosophical (Geach, 1967; Peacocke, 1992; Porter, 1868; Wagner 1973) work exists at- ‘tempting to explain the formation and structure of con- ‘cepts in general. It is beyond the scope of this paper to review such theories. Suffice ito say that all forms of cconceptualization involve cognitive-emotive processes whereby judgments are constructed. Concepts, in gen- cral, act as markers of real or abstract entities or refer- cents, The issue here is whether the concept of insight refers to either the ontologieal or the epistemological definition of the phenomenon of insight. If the former, then its ontology will extravasate a concept which will not be able to capture the full reality of insight; if the latter, a diferent situation occurs: namely, the concept ‘willbe broader than the phenomenon. This results from the fact that, because insight is observer determined, in addition to elements pertaining to the patient, it will include the cognitive contribution of the clinician (pre- vious experience, general knowledge, attitudes, ete.) and his/her negotiation with the patient (i.e, the prag- 746 -MARKOVA AND BERRIOS maties of the situation). In this ease, the concept of insight becomes a composite construct that does far more than mirror the phenomenon in its ontological sense: indeed, it creates a bridge between the patient and its context. Exploring and developing possible structures to understand this bridging function, and enabling the systematic delineation of the phenomenon itself is the aim of the next section ofthis paper. Differentiating between the concept and phenome- non of insight is important not justin highlighting the contribution of “distorting factors. It may also aid a rmore systematic “translation” from theory to practice by enablinga structured exploration of the components of the concept of insight and relating these to the fac- tors involved in their expression and modulation. ‘The Structure of Insight as a Concept ‘A range of different terms have been used to define insight, such as judgment (Jaspers, 1963), attitude (Lewis, 1954), verbalized awareness (Eskey, 1958), ree- ‘ognition (Heinrichs et all, 1985; Lin et al., 1979), ac- knowledgment (Bartk6 et a, 1988), and self-knowledge (Markova and Berrios, 19924), All of these terms have different meanings and imply different processes. Nev- ertheless, they can all be considered secondary pro- cesses and preceded, as others have remarked (Amador et al, 1993; Jaspers, 1963; Lewis, 1934; Markova and Berrios, 1992a), by an initial awareness of experience or change on the part of the patient, What does this mean? What kind of awareness is being referred to? What sort of change or experience does this relate to? Taking the relational aspect first, awareness must in theory relate to any change along a continuum of nor- mal to pathological experience, and the issue is that the latter may not just refer to any point along the pathway of symptom formation (for more on symptom formation pathways, see below), but should be spe- cifled with reference to symptom, syndrome, or dis- ease. We would propose, therefore, that as a first step toward building up astructure of the concept of insight, it might be helpful to distinguish between insight in relation to symptoms and insight in relation to disease. Insight in Relation to Individual Symptoms Before relating insight to individual mental symp- toms, one has to consider the ways in which symptoms arise. Elsewhere (Berrios and Markova, in press-b) a ‘model has been proposed describing some of the path- ‘ways that may be involved in the formation of mental ‘symptoms. This model is based on the view that de- clared “symptoms” are concepts jointly constructed by the patient and the clinician, whose relative contribu- tion may vary according to the particular pathway of symptom formation. Because symptoms are formed, expressed, and elicited in different ways, the term symptom embraces a wide range of heterogeneous con structs (Markova and Berrios, 1995). In this model, in- sight is considered an omnipresent process that attends the formation of mast symptoms. If so, itis necessary {to examine insight construction alongside some of the possible different pathways involved in symptom for- mation. Since this is not the place to describe the symp- tom formation model in detail (see Berrios and Mar- kové, in press-a, for full description), only a brief account will be offered of three of such pathways, and then attention will be turned to insight construction in relation to these. Pathway (a) A signal" issuing from a pathological lesion/process will penetrate consciousness and generate a formless, inchoate experience which we have termed the primor- dial soup (PS) (Figure 1). This as yet unnamed experi- ence needs to be conceptualized before it becomes a “symptom.” The process of conceptualization is likely to involve a number of cognitive processes whereby a Judgment of the =-perience is constructed that will be clevendent on factors such as previous experience, general knowledge, intelligence, cultural and environ- mental contexts, capacity and inclination to organize Information, ete. For example, a PS experienced ab initio as “fuzzy” and “unpleasant” might be con- structed as somatic discomfort, depressed mood, am ety, or depersonalization. The final construct will also be determined by the patient's capacity to verbalize and the clinician's own constructiorvinterpretation. It is clear from this first pathway that construction pro- cesses operate on the basis of awareness of change in the patient. In other words, the conscious awareness of an abnormal experience resulting from pathological brain signaling is subjected to the various factors men- tioned above, and thus structured finally into a symptom. Jo. Primary constructions (a) primary constuction of primor

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