insight and psychosis (2023)

Table of Contents

"Among the ambiguities that are of greatest clinical importance and cause the most confusion is the term INSIGHT."

—Zilboorg (1952)

A good result requires better adhesion, an essential prerequisite for this is good vision!

Insight is an important and crucial dimension in clinical psychiatry as a component of phenomenology and clinical examination, as an important diagnostic criterion and also in the assessment of competence in various situations such as: willingness to treat, informed consent, executor. , in criminal responsibility, etc. Insight is not an all or nothing phenomenon or a static state of mind. However, a dynamic expression that is strongly influenced by the clinical state of the individual, also by the sociocultural environment. Involuntary treatments and regulatory oversight of psychiatric clinical practice are the consequences of accepting "lack of knowledge" in a group of patients with psychiatric disorders!

Impaired Insight can be broadly defined as - Decreased ability to comprehend the "OBJECTIVE" reality of the self (body/mind) situation.

Aubrey Lewis (1934) tried to define insight as "a correct attitude towards morbid changes in oneself", but added that the terms "correct attitude", "morbid" "change" require discussion, reflecting the inevitable subjective emphasizing the bias in the interpretations !

Jaspers (1964) defined insight as "an objectively correct assessment of the severity of the disease and an objectively correct assessment of its particular nature".

Carpenter (1973) defined insight as a symptom of schizophrenia (SCZ) scored as merely present or absent, and according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision: "Deficient insight is a manifestation of the disease rather than a coping strategy”.

Anthony S. David, 1990[1] defined the concept of knowledge with at least three different dimensions:

  1. The realization that one is mentally ill (conscience).

  2. The ability to rename unusual mental events (delusions and hallucinations) as pathological (attribution).

  3. Recognize the need for treatment (action).

This indicates that (in)awareness, (mis)attribution, (in)action, either alone or together, define impaired vision. All three mental abilities appear to require some level of executive functioning and could be viewed as executive functioning in their own right, suggesting that shortsightedness is an impediment to executive functioning.

Amador and David[2] expanded the concept of knowledge to include five different dimensions of knowledge in SCZ:

  1. Awareness of having a mental illness.

  2. Awareness of the consequences of mental illness.

  3. Awareness of the symptoms of a mental disorder.

  4. Assignment of symptoms to a mental disorder.

  5. Awareness of the effects of medication.

Some current definitions of insight include the following:

"The level of personal awareness and understanding".

"The conscious recognition of one's own medical condition".

"A person's ability to understand the nature, meaning, and severity of their own illness."

(Video) How to gain insight into your illness | Am I actually sick?

Pseudo-insight: Jaspers cautioned that patients could occasionally recognize "morbid changes" simply by "rubbing over heard explanations," which is common in inpatient settings, particularly in involuntary patients.

In the routine mental status examination, perception is assessed as follows:

  1. Total denial of the disease.

  2. Slight awareness of being sick and needing help but denial at the same time.

  3. Being aware of being sick, but blaming other external events for it.

  4. intellectual insight.

  5. True emotional perception.

Lack of insight has been variously conceptualized as:

  1. Due to neuropsychological deficits.

  2. Part of the primary psychiatric illness itself, a symptom.

  3. A form of defensive denial... stigma, anguish.

This conceptual epistemological model has been criticized as "Eurocentric"... Saravananet al.argued “knowledge as a sociocultural process”. “Therefore, naturalistic (“Western”) explanations (eg, disease, anomaly, infection, degeneration) can coexist with personalistic (“Oriental”) explanations (eg, supernatural causes, sin and punishment, karma). Many patients (and their families) simultaneously seek biomedical and non-biomedical interventions.”[3,4,5]

Clinical Aspects of Insight in Psychosis,[6], in particular SCZ, have been studied in relation to and in relation to various factors such as e.g.:

  1. perception and severity of the disease.

  2. Therapeutic compliance, outcome and quality of life.

  3. insight and empowerment.

  4. Acumen and stage of illness: Illness stage and duration are some moderating factors in acuity of recent versus chronic psychosis.[7,8]

Insight is considered a state-dependent phenomenon in bipolar disorder (Nasser Ghaemiet al.), with reports of patients gaining complete vision after episodic recovery and a condition similar to a feature in SCZ. The fact is that we talk about "recovery" for bipolar disorder and "remission" for SCZ, and this state of "knowing as trait" may require rethinking in the future as we help SCZ patients "recover," don't just adopt!!!

The association between insight and depressive symptoms warrants further discussion here. Good knowledge of the disease in patients with SCZ is not only related to medication intake and high service commitment, but also to depression, low self-esteem and poor quality of life, which is a somewhat depressing consequence! !

Look thoughet al., 2009 reported: "Insight Paradox" and emphasized that the association of insight with depression is moderated by stigma.

  • Patients with good knowledge who are not bogged down by stigma turn out to be the "best" on various outcome measures.

  • Patients with a good perception but who “bear the burden of stigma” have been found to be at the highest risk of depression and also of suicide.

  • The clinical implication is that, in an attempt to increase awareness, perceived stigma must also be specifically addressed. Simply put and it makes sense; but the task is huge with very big time and space constraints! Improving perception requires individual attention and guidance and is an achievable goal! Reducing (as well as eliminating) stigma requires interventions on the world stage that consider a variety of factors: cross-cultural differences in attitudes, individual idiosyncrasies, magical and religious belief systems, placebo effects, generations behind in absorbing scientific advances that do too much. politics will require will to facilitate the process!!!

    (Video) Clip 3 - Psychosis and Insight - Marieke Pijnenborg

Various scales available to assess perception[6] contain:

  • Scale to assess ignorance of mental disorders.

  • Insight questionnaire and treatment adjustment.

  • Perception scale (IS).

  • lack of insight index.

  • Insight-Expanded Assessment Program.

  • Beck Cognitivo IS.

  • Existing state exam.

  • Schedule for mood disorders and SCZ.

  • Positive and negative syndrome scale.

  • Hamilton-Depression.

Models of insight in psychosis:

we would closeet al.2008[9] described in their review a lack of understanding of SCZ as and in relation to:

  • Positive symptom – “madness for health”.

  • Negative Symptom — Pathological Deficit, — “Mental Withdrawal”.

  • Disorganized symptom – Cognitive disorganization.

  • Denial - Defense tempered by stigma.

  • Biomedical model.

  • sociocultural model.

  • Misattribution: Cognitive errors due to lack of information, systematic bias, or idiosyncratic beliefs.

  • Neuropsychological model: Wisconsin Card Sorting Test performance, specifically the Persevering Error Score, shows a replicated association with measures of cognition, suggesting:

    1. Deficiencies in the conceptual organization.

    2. Reduced flexibility in abstract thinking.

      (Video) How psychosis bends your reality - BBC

    3. Impaired executive function.[10]

  • Metacognitive Impairment: Impaired metarepresentation and impaired self-reflection (a component of Beck's cognitive perception) relate lack of perception to neuropsychological perspective.

It will be relevant to discuss the insight-anosognosia model[11] Specific to Findings of Neuropsychological Deficits: Anosognosia is a recognized neurological deficit and shares striking similarities with impaired perception.

Both have:

  1. A serious lack of awareness of their shortcomings.

  2. A strong desire to prove one's claims.

  3. Inventing confabulations to explain the pathological symptoms.

  4. Often detectable deficiencies in the frontal lobe.

Neuropsychological and neuroanatomical data reveal similarities between impaired insight in SCZ and anosognosia in neurological patients, paving the way for the hypothesis that insight function is primarily mediated through frontal cortical structures, the dorsolateral prefrontal cortex, and orbitofrontal cortex, along with parietal cortical involvement. ..

This led to more in-depth neuropsychological and neuroimaging studies to understand intuition, using methods that were very innovative and specifically attempted to examine different components: metamemory, self-assurance, self-reflection, awareness, and attributional components of intuition.

Findings from various neurobiological studies[10,12,13,14] can be summarized as follows: there is accumulating evidence that insight deficits may be mediated by persistent cognitive dysfunction, mainly related to deficits in the frontal cortical systems. There is a "Cortical Midline System" (CMS): the medial frontal (ventromedial, Brodmann areas [BA] 10, 11 and dorsomemedial BA 9) and the cingulate cortex, called the anterior CMS, i.e., reliable in tasks involving that they encompass the self-reflection most commonly employed when contrasting 'self-assessment' with 'assessment of others'. (Are they talking about you/are they talking about others?) Self-reflection tasks in normal subjects demonstrate activation of the above CMS. Patients with SCZ did not show this increase, which is interpreted as "LACK OF DIFFERENTIATION BETWEEN SELF AND OTHERS...".

Subsequent studies in neuroimaging attempted to distinguish whether the two crucial dimensions of misperception (ignorance and misattribution) are represented differently in brain function. Early results suggest that —ignorance versus misattribution:

  • Exclusively: The midportions of the anterior cingulate cortex, the posterior cingulate cortex, and the inferior and superior parietal lobes have been associated only with ignorance and not with misattribution...

  • Robust – Posterior CMS activations – Precuneus and posterior cingulate with unconsciousness…

Ignorance has been associated with more widespread white matter deficits than misattribution...

"...Symptom unawareness may be a function of a more complex brain network, and symptom misattribution may be mediated by deficits in specific brain regions."[14]

In SCZ patients: Lack of differentiation between "self-reflection" and "other-reflection" is associated with less anterior CMS activity and more posterior CMS activity! Does the neurobiological finding of the inability to distinguish the "self" from the "other" in patients with SCZ reflect "ego boundaries dissolved in SCZ"? Is there an idea of ​​​​the phenomena "Hallucinations of running comments", "Transmission of thoughts"...

"Frith 1992 suggested that psychotic symptoms may result from an inability to distinguish between external events and changes in perception caused by the patient's own actions...the functional disconnect between the forebrain, which deals with actions, and the posterior areas involved in perception.”

"It is interesting to note that a few years later, Frith's hypothesis was supported by the results of this study, showing a pre-post shift in CMS activation in response to self-referential stimuli along with self-symptom understanding.

…Future research in this highly complex area of ​​brain function will require the development of a functional magnetic resonance imaging task to directly assess perceptual function under the scanner to further our understanding of the neurobiology of perception in SCZ.”[14]

Can perception be improved?

Various therapeutic measures include:

  • Pharmacotherapy, counseling... to alleviate the symptoms

    (Video) Are there any treatments for lack of insight in mental illness?

  • Cognitive Remedy – For cognitive/metacognitive deficits.

  • Psychoeducation, public awareness... to address denial/stigma/socio-cultural misconceptions.

  • Futuristic: biomarkers, images, laboratories... Diagnostic and therapeutic indicators can help!


Insight is multidimensional and complex. Poor perception of SCZ may need to be understood as more than just a primary symptom, but rather relates to implications for cognitive/metacognitive processes, emotional state, disease stage, and sociocultural processes. The psychopathological assessment of insight is characterized by several paradoxes... Neural correlates (prefrontal cortex) can promote understanding... It is essential to define the phenomenology of insight in SCZ that integrates neurobiological, psychological and social contexts...[15]


1.David AS insight and psychosis.Br J Psiquiatría.1990;156:798–808.[PubMed][Academic Google]

2.Amador XF, David AS, Editors. 2nd Edition Oxford, UK: Oxford University Press; 2004. Insight and psychosis: illness awareness in schizophrenia and related disorders.[Academic Google]

3.Tharyan A, Saravanan B. Insight and psychopathology in schizophrenia.Indian psychiatry J.2000;42:421–6. [Item without PMC][PubMed][Academic Google]

4.Saravanan B, Jacob KS, Prince M, Bhugra D, David AS. Culture and intuition reinterpreted.Br J Psiquiatría.2004;184:107–9.[PubMed][Academic Google]

5.Jacob KS. Assess knowledge across cultures.Indian psychiatry J.2010;52:373–7. [Item without PMC][PubMed][Academic Google]

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8.Quee PJ, van der Meer L, Bruggeman R, de Haan L, Krabbendam L, Cahn W, et al. Information about psychosis: The association with neurocognition, social cognition and clinical symptoms depends on the stage of the disease.Schizophrenic bull.2011;37:29–37. [Item without PMC][PubMed][Academic Google]

9.Osatuke K, Ciesla J, Kasckow JW, Zisook S, Mohamed S. Insight into schizophrenia: A review of etiological models and support research.Buy Psychiatry.2008;49:70–7.[PubMed][Academic Google]

10David AS, Bedford N, Wiffen B, Gilleen J. Metacognition failure and misperception in neuropsychiatric disorders.Philos Trans R Soc Lond B Biol Sci.2012;367:1379–90. [Item without PMC][PubMed][Academic Google]

11Professor DS, Lorenz J. Anosognosia in schizophrenia: Hidden in public.Innov Clin Neurosci.2014;11:10–7. [Item without PMC][PubMed][Academic Google]

12Shad MU, Tamminga CA, Cullum M, Haas GL, Keshavan MS. Insight and frontal cortical function in schizophrenia: a review.Schizofr. Nothing.2006;86:54–70.[PubMed][Academic Google]

13Bedford New Jersey. Illness denial in schizophrenia as a disturbance of perception and self-awareness Schizophrenia — Academic Dissertations [MESH] Institute of Psychiatry PhD Theses, University of London System No 001296598. 2009. p. 361. Erhaltlich bei:

14Shad MU, Keshavan MS. Neurobiology of perceptual deficits in schizophrenia: an fMRI study.Schizofr. Nothing.2015;165:220–6. [Item without PMC][PubMed][Academic Google]

15.Ouzir M, Azorín JM, Adida M, Boussaoud D, Battas O. Insight into schizophrenia: From conceptualization to neuroscience.Neurosci Psychiatric Clinic.2012;66:167–79.[PubMed][Academic Google]

(Video) Knowing me, knowing you: Insight in psychiatry and medicine


1. Josef Parnas: Insight into illness and double bookkeeping in schizophrenia
(Psychopathology and Phenomenology)
2. A small insight on Psychosis & Schizophrenia on occasion of World Schizophrenia Day '24th May'
(Kiran Hospital Surat)
3. Insight in Mental Illness
(Vijay Bhatia)
4. What to Do When a Loved One Has Anosognosia: Lack of Awareness
(Hope for Mental Health)
5. Metacognitive Reflection & Insight Therapy for Psychosis, with Paul Lysaker
6. What is Anosognosia?
(Living Well with Schizophrenia)
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