Insight and Judgment

Abstract

Abstract Insight and judgment are complex cognitive tasks that require the utilization and integration of several different mental functions, especially higher-level conceptual thinking. Prerequisites for insightfulness include the capacity for abstraction, ability to communicate (speech and language), intact cognitive function, absence of a thought disorder, euthymic mood, and stable affect (see Chapters 2 to 6). Even patients without disturbance of these functions may have poor insight as a result of using maladaptive psychologic defense mechanisms that distort the perception of internal and external realities or alter the motivation to relate openly with another person. In addition, the examiner needs to use his or her own abstract thinking in order to determine how insightful the patient is during the interview, because this determination is itself a subjective judgment. Evaluation of the patient’s insight and ability to make sound judgments is based on both the content and the process of the interview (see Chapter 1 ). In general, the more severely ill a psychiatric patient is, the more likely it is that his or her capacity for insight will be impaired. In order more fully to explore these constructs of insight and judgment, this chapter introduces the concepts of defense mechanisms and personality. These factors may adversely impact on decision making and insight, even in the setting of intact language and cognition. Although there are slightly different psycho-analytic views about defense mechanisms and their definitions, we have chosen to mostly rely on Vallaint’s (1977) descriptions. Even though specific personality styles or disorders are not documented in the MSE (but, rather, in the Assessment section of a written psychiatric evaluation because they represent diagnoses), predominant defense mechanisms should be described in the Insight and Judgment section of the MSE if they impact on the patient’s capacity for attaining adequate insight and judgment about his or her illness and life events.